Dialysis in the ElderlyDialysis in the Elderly

Zalman Suldan MD, PhD

Dialysis in the ElderlyDialysis in the ElderlyWhat is “Elderly”What is “Elderly”

Merriam Webster’s Online Dictionary: Main Entry: 1el·der·ly ◦Pronunciation: \ˈel-dər-lē\◦Function: adjective ◦Date: 1611◦1 a : rather old; especially : being past

middle age b : old-fashioned2 : of, relating to, or characteristic of later life or elderly persons

◦— el·der·li·ness noun

Dialysis in the ElderlyDialysis in the ElderlyWhat is “Elderly”? - Other What is “Elderly”? - Other

definitionsdefinitionsAARP – Association for the Advancement

of Retired Persons

◦Can now join at 50 years oldSocial Security (or Medicare!)

◦Retirement age – 66 years old (will be 67 in several years)

Age at which major Medical Issues tend to start occurring…◦60? 70? 80?

Dialysis in the ElderlyDialysis in the ElderlyWhat is “Elderly for Dialysis”What is “Elderly for Dialysis”England

◦ Socialized medicine does not pay for dialysis above 65 years old – is this really true??

◦ “According to Age Concern… four out of ten coronary units have age limits on the use of anti-clotting drugs after heart attacks, and two-thirds of kidney patients in their seventies are not accepted for dialysis or transplants.” Thursday, 17 December 1998

Other countries?

United States◦ USRDS stratification of data:◦ 45-64 yo; 65-75 yo; 75 yo and above

Dialysis in the ElderlyDialysis in the ElderlyWhat is “Elderly for Dialysis”What is “Elderly for Dialysis”Personal feelings:

◦What do you think?◦Have you ever had older family

members (or close friends) who have needed dialysis?

Dialysis in the ElderlyDialysis in the ElderlyUSRDS DataUSRDS DataIn 1980, there were:

9,206 people 64-75 on dialysis and 2,790 people >75

By 1990: 35,572 (64-75) and 18,304 (>75)

By 2007: 102,627 (64-75) and 81,434 (>75)

(WOW!)

Dialysis in the ElderlyDialysis in the ElderlyUSRDS DataUSRDS DataIn 1980, there were:

273.4 people per million >75yo 289.2 people per million total population

By 1990: 1,603.9 people per million >75yo 807.30 people per million total population

By 2007: 5,124.1 people per million >75yo 1664.90 people per million total

population

Dialysis in the ElderlyDialysis in the ElderlyUSRDS DataUSRDS DataBetween 1980 and 2007 the rate

of elderly dialysis increased by almost 19 fold while dialysis in the general population only increase 6 fold.

Dialysis in the ElderlyDialysis in the ElderlyUSRDS DataUSRDS DataWhat does this mean???

Dialysis in the ElderlyDialysis in the ElderlyUSRDS DataUSRDS DataWhat does this mean???

Dialysis in the Elderly is an important topic to discuss!

Dialysis in the ElderlyDialysis in the ElderlyUSRDS DataUSRDS DataWhat does this mean???

Dialysis in the ElderlyDialysis in the ElderlyUSRDS DataUSRDS DataWhat does this mean???

Dialysis in the Elderly is a topic that NEEDS TO BE DISCUSSED!

Dialysis in the ElderlyDialysis in the ElderlyUSRDS DataUSRDS DataAverage life expectancy on

dialysis:◦Patient > 75yo: approximately 4 ½

years (Nephsap January 2010)

◦Woman > 65yo with diabetes: 2 years (CanUSA study data)

Dialysis in the ElderlyDialysis in the ElderlyUSRDS DataUSRDS DataAverage life expectancy on

dialysis:◦Patient > 75yo: approximately 4 ½

years (Nephsap January 2010)

◦Woman > 65yo with diabetes: 2 years (CanUSA study data)

Case of Mrs. A.

Case Studies I – Mrs. F.Case Studies I – Mrs. F.Mrs. F. is:

◦ 94 years old◦ Lives in an independent-living apartment

with her husband◦ She has hypertension, which is the cause

of her chronic renal failure.◦ Her Creatinine Clearance is 4 ml/min (yes,

4!)◦ She has no overt uremic symptoms.◦ Her BUN is generally in the 60’s.◦ Has lots of side effects from her

antihypertensive medications◦ Is otherwise active, except for her many

doctor appointments

Case Studies II – Mr. A.Case Studies II – Mr. A. Mr. A. is:

◦ 73 years old◦ Has severe COPD and systolic congestive heart failure◦ Also has atrial fibrillation and a seizure disorder ◦ Has had repeated admissions to the hospital for COPD

(vs CHF) exacerbations◦ Has had a constant battle between aggressive diuresis

for optimization of cardio-pulmonary function and less aggressive diuresis to protect renal function

◦ Has pruritis, loss of appetite, occasional nausea

Compare also with Mr. H.: ◦ has severely compromised systolic function (EF 17%)◦ is unable to even stand up from bed without becoming

short of breath

Case Studies III – Mr. N.Case Studies III – Mr. N.Mr. N. is:

◦ 93 years old◦ Has severe aortic valve stenosis and severe

diffuse and inoperable (and nonstentable) coronary artery disease

◦ Has congestive heart failure as a result of the AoS

◦ Also has COPD and a chronic GI bleed (also inoperable)

◦ Is too high risk for the OR even for an AV Fistula!◦ 1 year ago was told by cardiology he had <

3months to live◦ He had said for a long time, while in CKD, that

he would never go on dialysis but changed his mind - one year ago!! - at time of crisis after encouragement by his family

Case Studies: Mrs. F, Mr. A, Mr. Case Studies: Mrs. F, Mr. A, Mr. NN Mrs. F. is:

◦ 94 years old◦ Lives in an independent

living apartment with her husband

◦ She has hypertension, which is the cause of her chronic renal failure.

◦ Her Creatinine Clearance is 4 ml/min (yes, 4!)

◦ She has no overt uremic symptoms.

◦ Her BUN is generally in the 60’s.

◦ Has lots of side effects from her antihypertensive medications

◦ Is otherwise active, except for her many doctor appointments

Mr. N. is:◦ 93 years old◦ Has severe Aortic

stenosis and severe diffuse and inoperable (and nonstentable) coronary artery disease

◦ Has congestive heart failure as a result of the AoS

◦ Also has COPD and a chronic GI bleed (also inoperable)

◦ Is too high risk for the OR for even an AV Fistula

◦ 1 year ago was told by cardiology he had <3months to live

◦ He had said for a long time, while in CKD, that he would never go on dialysis but changed his mind - 1 year ago!! - at time of crisis after encouragement by his family

Mr. A. is:◦ 73 years old◦ Has severe COPD and

systolic CHF, afib and a seizure disorder

◦ Has had repeated admissions to the hospital for COPD (vs CHF) exacerbations

◦ Has had a constant battle between aggressive diuresis for optimization of cardio-pulmonary function and less aggressive diuresis to protect renal function

◦ Has pruritis, loss of appetite, occasional nausea

Compare also with Mr. H.: ◦ has severely

compromised systolic function (EF 17%)

◦ is unable to even stand up from bed without becoming short of breath

Dialysis in the ElderlyDialysis in the ElderlyWhat are the indications for What are the indications for dialysis – when does a patient dialysis – when does a patient “qualify”?“qualify”?When patient’s Creatinine

Clearance falls <15ml/minFluid overload that is

unresponsive to medicationsHyperkalemia(Severe acidosis)Uremic PericarditisUremia

Dialysis in the ElderlyDialysis in the ElderlyWhat can be gained/lost with What can be gained/lost with dialysis?dialysis? When patient’s Creatinine Clearance falls

<15ml/min, dialysis is generally recommended Better control of hypertension (often) Sometime hypotension and resulting

consequences Better fluid control (generally) Ability to monitor patient frequently (3x/week as

opposed to q2month – 2x/month) Change in lifestyle!!! Change in quality of life (may worsen; may

improve in some cases) Change in quantity of life (may shorten; may

extend in some cases) Fatigue All the other side effects patients feel with dialysis

Dialysis in the ElderlyDialysis in the ElderlyWhat are the Issues for the Elderly What are the Issues for the Elderly

in Particularin ParticularChange in quantity of life (often does not

extend life expectancy depending on comorbid conditions, but may extend life in some cases)

Change in quality of life and lifestyle (most often worsens, but may improve QOL in some cases)◦ Recent study in NEJM showed 47% of elderly

dialysis patients showed a significant functional decline in the first 6 months after starting dialysis

Hypotension and resulting consequences more common in the elderly

Ability to more frequently monitor patient (3x/week as opposed to q2month – 2x/month)

Fatigue more common in elderly

Dialysis in the ElderlyDialysis in the ElderlyMore Issues for the Elderly in More Issues for the Elderly in ParticularParticularAccess difficulties

◦Ability to get an AV Fistula Surgical risk Poor Vascular Candidates

Time required for maintenance of AV Fistula, Graft, tunneled catheter◦Thrombosis and tPA

Extra hours for tPA dwell Both out/in-patient declotting and admissions

for revisions◦Fevers

Dialysis in the ElderlyDialysis in the ElderlyMore Issues for the Elderly in More Issues for the Elderly in ParticularParticularAbility to do other forms of dialysis?

◦PD, home hemodialysis◦Decreased dexterity, sophistication

with technology, machines◦Lack of partner/caregiver able to help

MalnutritionSuitability for transplantDialysis may force person from

their home due to increase in level of care requirement (sometime to nursing home level)

The Elephant in the RoomThe Elephant in the RoomWhat are the ethical issues

involved in dialysis in the elderly?

The Elephant in the RoomThe Elephant in the RoomEthical IssuesEthical IssuesFutility of CareDetermining the wishes of a

patient◦Especially if dementia is present

Balancing Family concerns with patient’s wishes

Financial concerns of Families◦Taxes and the tax year of death◦Continuation of family pension

benefits while patient remains alive◦Etc…

Case Studies I – Mrs. F.Case Studies I – Mrs. F.Mrs. F. is:

◦ 94 years old◦ Lives in an independent-living apartment

with her husband◦ She has hypertension, which is the cause

of her chronic renal failure.◦ Her Creatinine Clearance is 4 ml/min (yes,

4!)◦ She has no overt uremic symptoms. ◦ Her BUN is generally in the 60’s.◦ Has lots of side effects from her

antihypertensive medications◦ Is otherwise active, except for her many

doctor appointments

Case Studies I – Mrs. F.Case Studies I – Mrs. F.Would Mrs. F benefit from

dialysis?

Case Studies II – Mr. A.Case Studies II – Mr. A. Mr. A. is:

◦ 73 years old◦ Has severe COPD and systolic congestive heart failure◦ Also has atrial fibrillation and a seizure disorder ◦ Has had repeated admissions to the hospital for COPD

(vs CHF) exacerbations◦ Has had a constant battle between aggressive diuresis

for optimization of cardio-pulmonary function and less aggressive diuresis to protect renal function

◦ Has pruritis, loss of appetite, occasional nausea

Compare also with Mr. H.: ◦ has severely compromised systolic function (EF 17%)◦ is unable to even stand up from bed without becoming

short of breath

Case Studies II – Mr. A.Case Studies II – Mr. A.Would Mr. A. benefit from

dialysis?

Would Mr. H. benefit from dialysis?

Case Studies III – Mr. N.Case Studies III – Mr. N.Mr. N. is:

◦ 93 years old◦ Has severe aortic valve stenosis and severe

diffuse and inoperable (and nonstentable) coronary artery disease

◦ Has congestive heart failure as a result of the AoS

◦ Also has COPD and a chronic GI bleed (also inoperable)

◦ Is too high risk for the OR even for an AV Fistula!◦ 1 year ago was told by cardiology he had <

3months to live◦ He had said for a long time, while in CKD, that

he would never go on dialysis but changed his mind - one year ago!! - at time of crisis after encouragement by his family

Case Studies III – Mr. N.Case Studies III – Mr. N.Would Mr. N. benefit from

dialysis?

Other issues… regulatory Other issues… regulatory issuesissuesNew CMS/Medicare push as of

2010-2011 to increase home-hemodialysis and PD◦Likely a much lower percentage of

the elderly will be appropriate candidates

◦This may lower the number of dialysis units available to the elderly dialysis patient

Other issues… regulatory Other issues… regulatory issuesissuesCMS bundling of dialysis fees as of

2010-2011◦ Costs of all meds related to dialysis will be

subtracted from the dialysis units’ reimbursement.

◦ There is talk that ALL meds prescribed by the nephrologist will be subtracted also

◦ Because the elderly tend to have significantly more medications than younger patients, depending on how bundling is instituted, this will lower the reimbursement for elderly (and sick) patients

◦ Again may lower the number of units willing to accept the elderly patient

Other issues… regulatory Other issues… regulatory issuesissuesGovernmental requirement for

>70% of patients in any given unit to have an AV Fistula at initial outpatient dialysis start◦AVFs may not be viable in many

elderly due to poor vasculature◦May be too high surgical risk◦[Cherry] Picking of patients by

dialysis units

What is needed?What is needed?Initiate discussion with patients

and families regarding their wishes and dialysis LONG BEFORE dialysis needs to be initiated◦Not always possible when patient

has not been referred early and/or when renal failure develops acutely

◦Should be multidisciplinary including physician, nursing, social work

What is needed?What is needed?Be quick to dialyze when

appropriate

Be slow to dialyze when appropriate

What else is needed?What else is needed?Need to find cheaper ways to

dialyze because the money just won’t be there in the future for many elderly patients the way CMS is moving

Need to find more easily tolerated and more easily accessible methods for dialysis for the elderly