Jenni Harrison CT2 August 2013

1. Considerations in starting a Patient with Advanced Frailty on Dialysis: Complex Biology meets challenging ethics. Clin J Am SocNeprol. 2013 Jul;8(8):1421-8. Swindler M. JenniHarrison CT2 August 2013

2. Overview • Frailty…….& Me • The paper – technical aspects & background • 3 issues to discuss: • Effects of frailty • ‘Renal Frailty Phenotype’ • Ethical aspects of renal care in an ageing population • My ‘extra slide’ • Conclusions & Discussion Image source: Google images

3. Frailty • What is frailty………?

4. Frailty ………a selection of Google Definitions: (a) 2001 Psychological Thriller starring Matthew McConaughey (b) physical or moral weakness (c) the quality or state of being frail (d) the state of being weak in health or body (especially from old age) Alternatively, a term which is becoming increasingly common, especially from Geriatricians Image source: Google images

5. Frailty & Geriatric Medicine • Two broad schools of thought: • Fried, Cardiovascular Health Study • 3 or more of: unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, low physical activity levels • Predominantly a research tool

6. Frailty & Geriatric Medicine • Two broad schools of thought: • Fried, Cardiovascular Health Study • 3 or more of: unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, low physical activity levels • Predominantly a research tool • Rockwood, Frailty Index • State of vulnerability that arises in relation to the accumulation of health deficits • Requires rating of at least 30 health states • Difficult to apply in practice

7. Frailty & Geriatric Medicine • Distinct from ‘ageing’ & ‘comorbidity’ • Remains an area of hot debate • A recognised concept of value, but still a question of how it is defined • Many believe we ‘just know’ who is frail • When scales are used, their role in decision-making/predicting outcomes is questioned (Wou et al. 2013) • Scales/scores not used routinely in practice • ‘Difficult to operationalise’

8. ……& Me A time to confess my conflicts of interest • Trainee geriatrician • Special interest in dementia and advanced care planning • New to your department

9. Single author, Mark Swindler New York Review article 2013 Image source: Google images

10. Background • ‘Explosion’ in >80yr-olds with co-morbidities and geriatric syndromes (inc frailty)

11. Background • ‘Explosion’ in >80yr-olds with co-morbidities and geriatric syndromes (inc frailty) • Dialysis ‘routine practice in the current environment of procedure-driven medical care and biomedicalisation of aging’

12. Background • ‘Explosion’ in >80yr-olds with co-morbidities and geriatric syndromes (inc frailty) • Dialysis ‘routine practice in the current environment of procedure-driven medical care and biomedicalisation of aging’ • Growing group with no absolute contraindications for RRT, but are at risk for early mortality, increased hospitalisation, acceleration of geriatric syndromes and significant symptom burden

13. Background • ‘Explosion’ in >80yr-olds with co-morbidities and geriatric syndromes (inc frailty) • Dialysis ‘routine practice in the current environment of procedure-driven medical care and biomedicalisation of aging’ • Growing group with no absolute contraindications for RRT, but are at risk for early mortality, increased hospitalisation, acceleration of geriatric syndromes and significant symptom burden • ‘…..patients and families are struggling with saying no to dialysis therapy”

14. The effects of frailty – the WHAT • The case is forwarded that: • Dialysis patients (compared to cancer & HF) • More hospitalisations • More ICU admissions • More hospital deaths (less hospice use) • 29% had at least 1 ‘life-sustaining’ interventions (mechanical ventilations, CPR, feeding tube insertion)

15. The effects of frailty – the WHAT • The case is forwarded that: • Dialysis patients (compared to cancer & HF) • More hospitalisations • More ICU admissions • More hospital deaths (less hospice use) • 29% had at least 1 ‘life-sustaining’ interventions (mechanical ventilations, CPR, feeding tube insertion) • 1st year mortality dialysis patients >80 yrs up to 46% • In Nursing Home patients mortality rose, up to 58%

16. The effects of frailty – the WHAT • The prevalence of frailty in the CKD population is ~2x of general geriatric OP community • Frailty assoc. with starting dialysis at a higher eGFR as well as increased mortality (attenuated when correcting for frailty) • Suggested due to ‘overlap with signs of uraemia’ • Frailty is ‘under-diagnosed’ because of the lack of uniform definition and diagnostic criteria

17. Life expectancy Frail vs. Healthy

18. The ‘renal frailty phenotype’ – the WHO

19. ‘Cycle of Frailty’ – trigger entry points

20. Frail renal phenotype

21. Ethical considerations – the WHY • Complications • Sudden death; cardiovascular events; recurrent and prolonged hospitalisations; infections; need for long-term care; ICU admissions; chronic critical illness; increasing frailty; functional decline; loss off independence and dialysis discontinuation with average survival of 8-10 days • “There is no evidence that dialysis can reverse geriatric syndromes like frailty, functional disability and dementia”

22. Ethical considerations – the WHY • Patient’s preferences for dialysis were incorrectly predicted by surrogates/family/doctors up to ONE THIRD OF THE TIME • Families consistently over-estimating patients’ desires to continue dialysis • CKD & Dialysis patients experience a significant symptom burden ?inadequately assessed, ?underuse of palliative care

23. Ethical considerations – the WHY

24. ‘Extra Slide’ • Treat with caution ‘models’ to predict risk • Inclusivity • Referring back to ‘Frail Renal phenotype’ • Multitude of overlapping factors (age, disability, risk of sudden death, dementia, comorbidities, NH residence) • Origins? • How helpful is this really? • …..vs clinical judgement, individualised assessment?

25. ‘Extra Slide’ • Treat with caution ‘models’ to predict risk • Exclusivity • An anecdote from Intercalated BSc (courtesy of University of Glasgow) • ABCD score TIA risk prediction • Applied to clinic cohort • …….BP not predictive factor for stroke/all-cause mortality • Depends on population used to derive the score/scale

26. Other Relevant Guidance • GMC Guidance (2010) Treatment and care towards the end of life: good practice in decision making http://www.gmc-uk.org/guidance/ethical_guidance/end_of_life_care.asp (Supersedes the previous guidance “Withholding and withdrawing life-prolonging treatments”)

27. References • Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Med Sci. 2001;56(3):M146-56. • Moorhouse P, Rockwood K. Frailty and its quantitative clinical evaluation. J R Coll Physicians Edin. 2012;42:333-40. • Wou F, Gladman JR, Bradshaw L, et al. The predictive properties of frailty-rating scales in the acute medical unit. Age Ageing. 2013;May 10. Epub ahead of print.

28. Conclusions & Discussion • Frailty and Nephrology • WHAT • WHO • WHY • Potential pitfalls in screening tools OVER TO YOU……….