Improving outcomes for older people with advanced kidney

disease

Professor Edwina Brown Imperial College Renal and Transplant Centre

Hammersmith Hospital, London

Dialysis population is old and ageing!

UK Renal Registry Reports 2007, 2014

2013 • Median age HD – 66.9 years • Median age PD – 63.7 years

2006 • Median age HD – 65.0 years • Median age PD – 59.9 years

Increasing prevalence of “old old” on RRT

UK Renal Registry

RRT prevalence by age (per million age related population)

75-84 yrs >85 yrs

2009 5463 1030

2014 6647 1507

↑ 22% 46%

Questions

• What are challenges of providing dialysis for the ‘old old’?

• How has your renal unit practice adapted to the ageing of the dialysis population?

Distribution of dialysis modality in prevalent RRT patients in UK

%% 8.5 10.5 13.3 14.4 15.6 15.2 20.5 17.7 %

UK Renal Registry 2014

% PD

Q. 3D HD is optimal dialysis modality for older patients

114 questionnaires, British Renal Society 2015

Questions

• How would you have answered BRS question?

• Should more ‘old old’ be on PD?

Rembrandt: Portrait of an Old Man in Red

Sorrowing Old Man (‘At Eternity’s Gates’) by van Gogh

Phases of old age 1. Independent

Phases of old age 1. Independent 2. Decline in physical

and/or cognitive function

Phases of old age 1. Independent 2. Decline in physical

and/or cognitive function

3. Frailty and end of life

Ageing

“Young men be not proud in the presence of a decaying old man; he was once that which you are, he is now that which you will be.”

Clement III (reigned 1187-1191) Returned Papacy to Rome by signing treaty with Roman citizens to allow them their own magistrates. Died age 61

Published 2014 by The King’s Fund

Components of care for older people

Components of care all relate to advanced kidney disease

• Live well with 1 or more long-term conditions

• Support for complex co-morbidities and frailty

• Accessible effective support in crisis

• High quality person-centred acute care

• Good discharge planning and post-discharge support

• Effective rehabilitation and re-ablement

• Person-centred dignified long-term care

• Support, control and choice at end of life

Outline of talk

• Frailty – diagnosis and assessment

• Impact of frailty on outcomes

• HD or PD

• Assisted PD outcomes

• Challenges of care for older patients – HD and PD

• Can we improve care?

Common clinical presentations of frailty

• Non-specific: extreme fatigue, unexplained weight loss and frequent infections

• Falls: balance and gait impairment important risk factors and are major features of frailty

• Delirium: rapid onset of fluctuating confusion when admitted to hospital. Associated with adverse outcomes

• Fluctuating disability: day to day instability resulting in good and bad days

Increased vulnerability

Clegg et al, Lancet 2012

Assessing frailty: should be routine nephrological care for older patients • History:

– daily activities of patient

– how much help with these?

– any change in physical activity?

– any weight loss?

– any falls?

• Examination:

– walking speed into clinic and use of aids

– muscle mass and strength

– obvious weight loss

Cognitive Function

• Do not rely on simple conversation – can hide significant cognitive dysfunction

• Cognitive impairment in CKD mostly related to vascular disease and affects executive function

• Simple memory tests, including MMSE, often normal

• Executive function tests include clock drawing (easy to do in clinic), Trail Making Tests, MOCA

Outline of talk

• Frailty – diagnosis and assessment

• Impact of frailty on outcomes

• HD or PD

• Assisted PD outcomes

• Challenges of care for older patients – HD and PD

• Can we improve care?

Cranach: Fountain of Youth

Implications of being ‘frail’

• Associated with worse physical function and quality of life

• High incidence of geriatric syndromes – falls, delirium, cognitive impairment, dementia

• Increased admissions to hospital and prolonged lengths of stay

• Increased mortality

True for all conditions – not just dialysis

FEPOD: Frailty is principal predictor of

outcomes and dialysis modality (aPD cf HD)

Iyasere O et al: CJASN 2016

Outcome Predictor Multiplicity

Adjusted P-value

Effect Size (95%

CI)

Illness Intrusion Age <0.01 0.98 (0.97 – 0.99)

SF12 PCS Frailty <0.01 0.90 (0.88 – 0.93)

SF12 MCS Frailty <0.01 0.94 (0.91 – 0.97)

Illness Intrusion Frailty <0.01 1.14 (1.09 – 1.24)

Barthel Index Frailty <0.01 0.89 (0.86 – 0.93)

Symptom burden Frailty <0.01 1.23 (1.13 – 1.33)

Renal Treatment

Satisfaction

HD vs PD 0.03 0.93 (0.89 – 0.98)

Admission ADL score predicts death in hospital and discharge to assisted care facility in dialysis patients

Sood et al, AJKD 2011

Outcomes for 390 patients starting HD 2009-2013 stratified by frailty score – Halifax, Canada

Alfaeedel TA et al, CJASN 2015

Outline of talk

• Frailty – diagnosis and assessment

• Impact of frailty on outcomes

• HD or PD

• Assisted PD outcomes

• Challenges of care for older patients – HD and PD

• Can we improve care?

Choice of dialysis modality

• No difference in survival on HD compared to PD

• Decision should therefore be made with patient dependent on patient goals, lifestyle and medical concerns

• Availability of assistance enables older patients to have dialysis at home – assisted PD considered first line treatment for older frail patients in France

Need for patient-centred care

• What matters to patient?

– Travel?

– Caring for spouse?

– Grandchildren care?

– Length of life or quality of life?

– End of life priorities?

HD or PD in elderly: patient perspective

HD or PD in elderly: patient perspective HAEMODIALYSIS

• Hospital based treatment – Not dependent on patient ability

– Can provide social structure for frail elderly

– Transport (journey and waiting time) needs to be added into treatment time

– Often feel washed out for hours after HD session

• Interferes with social and family life

• Increased hospitalisation for vascular access problems

• Difficult to travel for holidays or visiting family

PERITONEAL DIALYSIS • Home based treatment

– Patient independence

– Fits in with work and social activities

– Can be done by carer (paid assistant or family)

• Less visits to hospital

• Flexibility of manual exchanges (3-4/day) or automated cycling machine over night

• Treatment burden related to daily and repetitive nature of performing exchanges

• Easier to travel to go on holiday or visit family nationally or overseas

HD or PD in elderly: doctor perspective

HD or PD in elderly: doctor perspective HAEMODIALYSIS

• Familiar with HD; complications regarded as part of treatment

• Well-established pathways so easy to organise

• Very few medical contraindications so less need to assess patient for medical and psycho-social eligibility

• Many older patients find it difficult to make decisions and too many barriers to education so takes less time just to put patient on to HD – or keep patient on HD if presenting acutely

PERITONEAL DIALYSIS • Often not familiar with PD

and only see patients with complications

• Perception that older patients cannot do PD so not offered

• Takes time to have discussions about treatment choices and give information so PD not offered or discussed

Benefits of PD for older patients • Treatment is at home

• Flexibility of treatment round social activities (CAPD) or at night with day-time freedom (APD)

• Enables travel

• Preservation of residual renal function – enables days off dialysis

• No haemodynamic swings and no periods of feeling “washed out” (as on HD)

• Simple procedure – so can be done by family member or paid assistant

BOLDE: Adjusted Illness Intrusion Ratings Scores for PD and HD

Significantly less illness intrusion in PD

P=0.032

Brown EA et al, NDT 2010

Potential obstacles to PD for older patients: age-related

POTENTIAL OBSTACLE POTENTIAL SOLUTION

Poor manual dexterity Assisted PD

↓physical function; difficulty in lifting bags

Assisted PD

Impaired vision Assisted PD

Impaired hearing Visual aids for training

Cognitive dysfunction Assisted PD; can be contraindication if advanced

General frailty Assisted PD

Late presentation (more common)

Acute start PD + assisted PD

Potential obstacles to PD for older patients: PD-related

POTENTIAL OBSTACLE POTENTIAL SOLUTION

Prior lower abdominal surgery Surgically placed catheter: PD can be contra-indicated

Severe obesity Surgically placed catheter; PD can be contra-indicated

Housing – no storage space More frequent so smaller deliveries

Depression / anxiety Assisted PD; can be contra-indication

Eligibility, choice and use of PD according to availability of home care

19 (37) 39 (47) Received PD

19(58) 39 (59) Choose PD if eligible

.06 33 (65) 66 (80) Eligible for PD

2 3 PD barriers, median

35 (42) 29 (57) Hospital start

21 (78) 60 (74) Predialysis care

.04 35 (68) 42 (51) Male

.02 66 75 Age, median

51 83 Patients

P No home care Home care

Oliver MJ et al: Kidney International (2007) 71, 673–678

Outline of talk

• Frailty – diagnosis and assessment

• Impact of frailty on outcomes

• HD or PD

• Assisted PD outcomes

• Challenges of care for older patients – HD and PD

• Can we improve care?

•Retrospective study of 1613 patients >75 years old who

started dialysis between 1.1.2000 and 31.12.2005

•Mean age at dialysis initiation was 81.9 ± 4.5 years

•89% on CAPD

•81.8% required assistance

Copyright restrictions may apply.

Castrale, C. et al. Nephrol. Dial. Transplant. 2009 0:gfp375v1-375; doi:10.1093/ndt/gfp375

Kaplan-Meier curves of patient survival according to the modality of assistance for elderly patients on peritoneal dialysis (log rank test: P < 0.001 for the autonomous versus the family-

assisted group and for the autonomous versus the nurse-assisted group, P < 0.001)

Median survival:

Autonomous – 48m

Family assisted – 26m

Nurse assisted – 24m

UK Renal Registry 11th Annual Report

10 year survival of incident RRT patients, 1997-2006 cohort

Median survival

75 yrs+: 22 mths

Outcome data for assisted PD

• Patient survival

• Technique survival

• Quality of life

Frail Elderly Patient Outcomes on Dialysis (FEPOD): Cross-sectional and longitudinal comparisons of assisted peritoneal dialysis and haemodialysis

Imperial NIHR Biomedical Research Centre

FEPOD cross-sectional data: Frailty is principal

predictor of outcomes and dialysis modality

(129 aPD patients cf 122 HD patients)

Iyasere O et al: CJASN 2016

Outcome Predictor Multiplicity

Adjusted P-value

Effect Size (95%

CI)

Illness Intrusion Age <0.01 0.98 (0.97 – 0.99)

SF12 PCS Frailty <0.01 0.90 (0.88 – 0.93)

SF12 MCS Frailty <0.01 0.94 (0.91 – 0.97)

Illness Intrusion Frailty <0.01 1.14 (1.09 – 1.24)

Barthel Index Frailty <0.01 0.89 (0.86 – 0.93)

Symptom burden Frailty <0.01 1.23 (1.13 – 1.33)

Renal Treatment

Satisfaction

HD vs PD 0.03 0.93 (0.89 – 0.98)

Outline of talk

• Frailty – diagnosis and assessment

• Impact of frailty on outcomes

• HD or PD

• Assisted PD outcomes

• Can we improve care?

What may improve care for older patients requiring dialysis – and what

are the barriers? • Patient centred care and shared decision

making with focus on well-being and goals of patient in relation to realistic prognosis

• Access to assisted PD

• Integration with services for older people in community and secondary care

What may improve care for older patients requiring dialysis – and what

are the barriers? • Patient centred care and shared decision

making with focus on well-being and goals of patient in relation to realistic prognosis

• Access to assisted PD

• Integration with services for older people in community and secondary care

Imperial College Healthcare: Integration with services for older people in community and secondary care

• Assessment • Access to

– Rehabilitation – “Hospital at home” – Social support in community – Rapid discharge planning

• Referral to palliative care support when appropriate

• Funded by – Imperial College Healthcare Charitable Funds (Jul 15 – Dec 16) – British Patient Kidney Association (Jan 17 – Jul 18)

• Modified Geriatric Assessments conducted on HD patients at one satellite Unit and PD unit. Patients aged > 70 years and over or those >60years but perceived to be frail are assessed.

• Assessment of Frailty – Canadian Study of Health and Aging Score - CSHA

• Abbreviated Mental Test Score (AMTS) : Memory /Dementia

Score ≤8 requires further screening for Cognitive Impairment/delirium

Score < 6 indication of dementia

• Clock Test Score: Measure of executive function/cognition

Score <8 indicates Cognitive Impairment

• Distress Thermometer : Validated in Renal patients

Score 1-10 Indicates distress

Referrals resulting from assessment are recorded

Assessments

Initial Assessment HD

Initial Assessment PD

6-Month Follow up HD

6-Month Follow up PD

Number (n)

58 32 34 24

Mean age (years)

78.2 ± 5.5 76.8 ± 6.1 75.0 ± 4.3 72.4 ± 3.4

Male (%) 63.8 (37/58) 65.6 (21/32) 50.0 (17/34) 20.8 (5/24)

Female (%) 36.2(21/58) 34.4(11/32) 50.0(17/34) 79.2(19/24)

% over 80 years

34.5 (20/58) 28.1 (9/32) 8.8 (3/34) 4.2 (1/24)

Period 1st 6 months - Patient Demographics

Results: Initial Assessment scores

Assessments HD 1st Assessment (n=58)

PD 1st Assessment (n=32)

Mild frailty score = 5 (%) 20 (34.5) 7 (21.9)

Moderate to severe frailty score= 6&7 (%) 26 (44.8) 15 (46.9)

Abbreviated Mental Test Score ≤ 8(%) 12 (20.7) 4 (12.5)

Clock Test Score <8 (%) 31 (53.4) 16 (50.0)

Distress Thermometer Score ≥ 5 (%) 16 (27.6) 8 (25.0)

Treatment Satisfaction Score ≤ 80% 23 (39.7) 4 (12.5)

Number of patients with falls in last year 15 (25.7) 9 (28.1)

Assessments HD 6-month F’up Assessment

(n=31)

PD 6-month F’up Assessment

(n=17)

Pre Post Pre Post

Mild frailty score = 5 11 10 3 4

Moderate to severe frailty score = 6&7 14 14 12 11

Distress Thermometer Score ≥ 5 12 3 4 4

Treatment Satisfaction Score ≤ 80% 11 7 4 0

Results: 6 month Follow-up

Of the 34 HD patients followed up - 3 were not reassessed (2 declined and 1 died) Of the 24 PD patients followed up - 7 were not reassessed (3 could not be assessed, 2 transferred out to other hospitals and 2 died)

Before

After

0

5

10

15

20

25

30

HD PD

4 2

27

14

Identification of Cognitive Impairment

Improved identification of Cognitive Impairment

Improving integration between renal and geriatric healthcare teams: Barriers

• Staffing and structures of renal units have not adapted for increasing ageing of patients

• Lack of defined pathways between renal and geriatric care teams

• Not even in curriculum for renal trainees

• Intuitively should be of benefit, but no evidence

• Resources – staffing and costs

Giorgione: La Vecchia