1 / 37

Dialysis in the Elderly

Dialysis in the Elderly. Zalman Suldan MD, PhD. Dialysis in the Elderly What is “Elderly”. Merriam Webster’s Online Dictionary: Main Entry: 1 el·der·ly Pronunciation: ˈel- dər - lē Function: adjective Date: 1611

ariana-dyer
Download Presentation

Dialysis in the Elderly

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Dialysis in the Elderly ZalmanSuldan MD, PhD

  2. Dialysis in the ElderlyWhat 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·nessnoun

  3. Dialysis in the ElderlyWhat is “Elderly”? - Other definitions • AARP – Association for the Advancement of Retired Persons • Can now join at 50 years old • Social 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?

  4. Dialysis in the ElderlyWhat 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

  5. Dialysis in the ElderlyWhat is “Elderly for Dialysis” • Personal feelings: • What do you think? • Have you ever had older family members (or close friends) who have needed dialysis?

  6. Dialysis in the ElderlyUSRDS Data • In 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!)

  7. Dialysis in the ElderlyUSRDS Data • In 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

  8. Dialysis in the ElderlyUSRDS Data • Between 1980 and 2007 the rate of elderly dialysis increased by almost 19 fold while dialysis in the general population only increase 6 fold.

  9. Dialysis in the ElderlyUSRDS Data • What does this mean???

  10. Dialysis in the ElderlyUSRDS Data • What does this mean??? • Dialysis in the Elderly is an important topic to discuss!

  11. Dialysis in the ElderlyUSRDS Data • What does this mean???

  12. Dialysis in the ElderlyUSRDS Data • What does this mean??? • Dialysis in the Elderly is a topic that NEEDS TO BE DISCUSSED!

  13. Dialysis in the ElderlyUSRDS Data • Average life expectancy on dialysis: • Patient > 75yo: approximately 4 ½ years (Nephsap January 2010) • Woman > 65yo with diabetes: 2 years (CanUSA study data)

  14. Dialysis in the ElderlyUSRDS Data • Average 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.

  15. 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

  16. 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

  17. 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

  18. Case Studies: Mrs. F, Mr. A, Mr. N • 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

  19. Dialysis in the ElderlyWhat are the indications for dialysis – when does a patient “qualify”? • When patient’s Creatinine Clearance falls <15ml/min • Fluid overload that is unresponsive to medications • Hyperkalemia • (Severe acidosis) • Uremic Pericarditis • Uremia

  20. Dialysis in the ElderlyWhat can be gained/lost with 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

  21. Dialysis in the ElderlyWhat are the Issues for the Elderly in Particular • Change 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

  22. Dialysis in the ElderlyMore Issues for the Elderly in Particular • Access 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

  23. Dialysis in the ElderlyMore Issues for the Elderly in Particular • Ability to do other forms of dialysis? • PD, home hemodialysis • Decreased dexterity, sophistication with technology, machines • Lack of partner/caregiver able to help • Malnutrition • Suitability for transplant • Dialysis may force person from their home due to increase in level of care requirement (sometime to nursing home level)

  24. The Elephant in the Room • What are the ethical issues involved in dialysis in the elderly?

  25. The Elephant in the RoomEthical Issues • Futility of Care • Determining 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…

  26. 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

  27. Case Studies I – Mrs. F. • Would Mrs. F benefit from dialysis?

  28. 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

  29. Case Studies II – Mr. A. • Would Mr. A. benefit from dialysis? • Would Mr. H. benefit from dialysis?

  30. 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

  31. Case Studies III – Mr. N. • Would Mr. N. benefit from dialysis?

  32. Other issues… regulatory issues • New 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

  33. Other issues… regulatory issues • CMS 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

  34. Other issues… regulatory issues • Governmental 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

  35. 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

  36. What is needed? • Be quick to dialyze when appropriate • Be slow to dialyze when appropriate

  37. 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

More Related