Should an Elderly Patient with Stage V CKD and Dementia Be Started on Dialysis?

Ying, Irene; Levitt, Zoe; Jassal, Sarbjit V.

doi:10.2215/cjn.05870513

Cited by 14 publications

(8 citation statements)

References 46 publications

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“…Our data may support the recommendation of the Renal Physician Association (RPA), which suggest that patients with advanced dementia be advised against initiation of dialysis, particularly when they are unable to cooperate with the dialysis process. [10,32] Supporting this recommendation, the Dialysis Advisory Group of the American Society of Nephrology suggested that dialysis patients with life expectancy of <1 year may desire a palliative approach to dialysis care, which focuses on aligning patient treatment with patients’ informed preferences. [9] The RPA emphasizes the need for establishing a strong therapeutic relationship and open communication to facilitate shared decision-making.…”

Section: Discussionmentioning

confidence: 99%

Pre-ESRD Dementia and Post-ESRD Mortality in a Large Cohort of Incident Dialysis Patients

Molnár

Sumida

Gaipov³

et al. 2017

Dement Geriatr Cogn Disord

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Background: Conservative management may be a desirable option for elderly, fragile, or demented patients who reach end-stage renal disease (ESRD), yet some patients with dementia are placed on renal replacement therapy nonetheless. Methods: From a nationwide cohort of 45,076 US veterans who transitioned to ESRD over 4 contemporary years (October 1, 2007 to September 30, 2011), we identified 1,336 (3.0%) patients with International Classification of Diseases, Ninth Revision, Clinical Modification code-based dementia diagnosis during the prelude (predialysis) period. We examined the association of prelude dementia with all-cause mortality within the first 6 months following transition to dialysis, using a propensity-matched cohort and Cox proportional hazards models. Results: In the entire cohort, the overall mean ± standard deviation age at baseline was 72 ± 11 years, 95% were male, 23% were African-American, and 66% were diabetic. There were 8,080 (18.5%) deaths (mortality rate, 412; 95% confidence interval [CI], 403-421/1,000 patient-years) in the dementia-negative group, and 396 (29.6%) deaths (mortality rate, 708; 95% CI, 642-782/1,000 patient-years) in the dementia-positive group in the entire cohort in the first 6 months after dialysis initiation. Presence of dementia was associated with higher risk of all-cause mortality (adjusted hazard ratio, 1.25; 95% CI, 1.12-1.38) compared to dementia-free patients in the first 6 months after dialysis initiation. Conclusion: Pre-ESRD dementia is associated with increased risk of early post-ESRD mortality in veterans transitioning to dialysis.

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Section: Discussionmentioning

confidence: 99%

Pre-ESRD Dementia and Post-ESRD Mortality in a Large Cohort of Incident Dialysis Patients

Molnár

Sumida

Gaipov³

et al. 2017

Dement Geriatr Cogn Disord

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“…These patients generally have difficulty to express their treatment-related symptoms. In addition, they are less likely to understand or to tolerate the dialysis process [8, 10, 19–21]. Several studies, including a recent nationwide population-based study in Taiwan, revealed that dementia is strongly and independently associated with morbidity and mortality not only in the general elderly population but also in ESRD patients [8, 10, 22–24].…”

Section: Introductionmentioning

confidence: 99%

Dementia is a risk factor for major adverse cardiac and cerebrovascular events in elderly Korean patients initiating hemodialysis: a Korean national population-based study

et al. 2017

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BackgroundDementia is common in end-stage renal disease (ESRD) patients on hemodialysis (HD) and is associated with worse outcomes. This study aimed to investigate the risk of major adverse cardiac and cerebrovascular event (MACCE) in elderly patients with dementia initiating HD.MethodsUsing the database from the Health Insurance Review & Assessment Service, we analyzed 10,171 patients aged 65 years or older who had initiated dialysis from 2005 to 2008. MACCE was defined as a composite outcome of all-cause mortality, nonfatal acute myocardial infarction, target vessel revascularization, and nonfatal ischemic and hemorrhagic stroke. The Kaplan-Meier method and Cox proportional hazards model were used, and further comparisons using propensity-score matching at 1:2 ratio were also performed.ResultsA total of 303 elderly patients (3.0%) had dementia at initiating HD. During follow-up, dementia was a significant predictor of MACCE after adjustment for confounding variables. In addition, further analyzed in the propensity-score matched groups, dementia was an independent predictor of both nonfatal ischemic stroke and all-cause mortality.ConclusionsDementia is an independent risk factor for mortality and ischemic stroke in elderly ESRD patients initiating HD. Patients with dementia who start dialysis should be closely monitored to reduce the risk of mortality and ischemic stroke.Electronic supplementary materialThe online version of this article (doi:10.1186/s12882-017-0547-0) contains supplementary material, which is available to authorized users.

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“…Dialysis requires patients to sit still for 4–5 hours and tolerate the sometimes traumatic insertion of fistula needles or other problems with vascular access. Patients who are confused or distressed might disconnect lines, disrupt equipment and put other patients at risk, requiring the use of physical or chemical restraint . The RPA/ASN guidelines emphasize that the ability to cooperate with dialysis is a prerequisite as restraint use constitutes undue treatment burden and an infringement of human rights.…”

Section: Dialysis Burden Of Care—issues For Patients With Dementiamentioning

confidence: 99%

The Overuse, Underuse, and Misuse of Dialysis in ESKD Patients with Dementia

MacPhail

Ibrahim

Fetherstonhaugh

et al. 2015

Seminars in Dialysis

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The profile of patients on chronic dialysis has shifted. There is a growing group of older patients with comorbid dementia and ESKD, who are at risk of overuse, underuse, and misuse of dialysis. Policy is lacking to help guide treatment decisions in this group. This paper explores clinical considerations specific to patients with comorbid ESKD and dementia. These include: the impact of comorbid dementia on dialysis effectiveness and feasibility; burden of care issues that are specific to patients with dementia; and capacity, autonomy, and consent. A better understanding of these issues may help guide discussions and decision making about treatment. For some older patients with multiple comorbidities including dementia, dialysis does not provide survival or quality of life benefit compared to medical management. These patients also experience additional treatment burden due to a 'dementia unfriendly' environment. However, exceptions may include patients who are younger, more independent, and have fewer comorbidities. Patients with dementia are often inappropriately assumed to lack capacity to participate in treatment decision making, and are at risk of having their preferences overlooked. Many patients with mild-to-moderate dementia remain capable of reporting their preferences and quality of life, and should always be involved in treatment discussions where possible.

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Should an Elderly Patient with Stage V CKD and Dementia Be Started on Dialysis?

Cited by 14 publications

References 46 publications

Pre-ESRD Dementia and Post-ESRD Mortality in a Large Cohort of Incident Dialysis Patients

Pre-ESRD Dementia and Post-ESRD Mortality in a Large Cohort of Incident Dialysis Patients

Dementia is a risk factor for major adverse cardiac and cerebrovascular events in elderly Korean patients initiating hemodialysis: a Korean national population-based study

The Overuse, Underuse, and Misuse of Dialysis in ESKD Patients with Dementia

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