Care of Elderly Dialysis and End-Stage Kidney Disease Patients

Exercise Training and Geriatric Rehabilitation

All patients, regardless of age group, should be reminded of the benefits they may gain from exercise training. Simple home-based programs, such as that used in the EXerCise Introduction To Enhance Performance in Dialysis (EXCITE) trial, can stimulate sufficient activity and mobility to be beneficial to both physical and mental health, particularly if maintained over longer periods of time. Exercise training while on dialysis can be provided by physiotherapists and occupational therapists if resources exist. Alternatively, it can be done independently, at home, or in the dialysis center, with readily available equipment such as leg resistance bands, light weights, or seated stationary bikes. Intradialytic exercise training programs have been shown to improve physical performance measures such as the 6-minute walk and timed up-and-go tests. Common cited barriers to participating in such programs include dialysis-related fatigue, lack of motivation, concern over intradialytic exercise safety, impact on dialysis staff workload, and reluctance to routine changes.

Geriatric rehabilitation is a well-defined area with good evidence for its efficacy. Interdisciplinary rehabilitation teams with expertise in caring for geriatric patients are usually involved. Rehabilitation can be provided in the inpatient or outpatient setting; however, inpatient geriatric rehabilitation programs may particularly help reduce the functional decline that occurs in association with dialysis initiation. Recent studies have shown that inpatient rehabilitation was associated with fewer patients requiring prolonged care in a skilled nursing facility or long-term care home. More than two-thirds experienced a clinically meaningful improvement in function with inpatient rehabilitation (defined as meeting all predetermined functional goals), while 90% met at least half the goals they had set by the time of discharge. Ideally, dialysis times should not conflict with times when the patient is most active and willing to participate in rehabilitation therapy. Rehabilitation has also been shown to be more effective if dialysis is provided on a strict schedule, with some suggestions that the use of short daily dialysis (i.e., 2 hours, 6 days a week) may be more effective.

Clinical Impact of Cognitive Changes

Several studies have shown that mortality, morbidity, and need for long-term care are higher in those with chronic kidney disease (CKD) and cognitive impairment. At the individual patient level, cognitive decline alters how well patients can manage self-care activities. Cognitive changes can indirectly impact health and quality of life. Executive dysfunction, as opposed to, for example, memory impairment, is one of the cognitive domains more commonly affected in dialysis patients, and consequently, tasks requiring planning, organization, self-control, and adaptability to change are differentially impacted. Health-related tasks, including medication and diet management, dialysis modality selection, and advance care planning (ACP), are also affected. Even mild cognitive changes are associated with a lower likelihood of being accepted to the kidney transplant waitlist and, in those who do get waitlisted, with lower survival to transplant surgery. Consequently, it is important to assess cognitive function prior to discussions about ACP, modality selection, survival prognosis, and future wellbeing.

Cognitive Assessment and Screening

Typical assessments done during routine dialysis sessions identify only a fraction (< 5%) of patients with cognitive impairment. As a result, it is recommended that some form of cognitive screening be included, although frequency and methods are left to the individual clinicians. There are several screening tests available that have been used in the clinical dialysis unit setting, including the Mini-Mental State Examination (MMSE), 3MS, Rowland Universal Dementia Assessment Scale (RUDAS), Montreal Cognitive Assessment (MoCA), and Mini-COG. The MMSE is less useful in highly educated patients, those with language or cultural barriers, or those with predominantly executive dysfunction. The 3MS is a modified version of the MMSE with four additional items that improve discriminatory power, particularly those with a higher level of education. The Mini-COG is a simple bedside test that is practical and favored because of its ease of use and short administration time. Finally, the RUDAS is the optimal tool for patients with educational, language, or cultural barriers. Based on recent data, the MoCA may be the most optimal single screening tool for use in the dialysis unit setting. It appears to be more generalizable, sensitive, and specific when compared with other tools. Ideally, the MoCA should be performed, in a quiet secluded area, either on a nondialysis day or within the first hour of dialysis (to minimize the possible impact of cerebral stunning on the test’s interpretation). Testing must be performed by trained individuals. A number of translated versions are available for those with language or cultural barriers, and a MoCA _BLIND version can be used for those with visual limitations. The recommended frequency and duration of screening remain unclear.

Management of Mild Cognitive Impairment and Dementia

Both nonpharmacologic and pharmacologic treatments have been used in the general population, with modest effects. Nonpharmacological interventions include cognitive rehabilitation and exercise programs. While useful, these can be challenging to organize around dialysis schedules. Collaboration with a geriatric specialist or occupational therapist to educate and support caregivers, assist with managing pharmacologic options, and help access community programs to maximize function and safety is advised. Pharmacological therapies, such as cholinesterase inhibitors prescribed to patients with mild-to-moderate dementia and the N -methyl- d -aspartate (NMDA) inhibitor memantine given to those with moderate to severe dementia, show, at best, modest effects at slowing the rate of deterioration (especially in the setting of probable Alzheimer disease). Side effects are dose dependent and include gastrointestinal, neurologic, and cardiovascular side effects related to cholinergic stimulation (the most common being dizziness and drowsiness). Also concerning are theoretical risks of weight loss, debility, and syncope. Unfortunately, only a few case reports using pharmacological interventions in dialysis patients have been published, so, if prescribed, patients should be monitored both for clinical benefit and for side effects. One additional concern of prescribing additional medications is increasing polypharmacy, noting that dialysis patients already have a heavy drug burden (see Polypharmacy section).

Behavioral and Psychological Symptoms of Dementia

Dementia is a progressive disease that may result in complex and often severe behavioral abnormalities. Sometimes referred to as behavioral and psychological symptoms of dementia, they encompass perceptual, emotional, or behavioral alterations such as hallucinations, repetitive movements, apathy, or impulsive behaviors (among others). Sometimes, patients can present with aggressive or unexpected actions, such as screaming or hitting, which can be dangerous for staff, the patient, and other patients, particularly within an HD center. Clear unit policies around the provision of dialysis and safety plans are advisable when patients begin to manifest these symptoms. It is advantageous to have previously had discussions with the family about the risk of behavioral and psychological symptoms of dementia.

A diagnosis of cognitive impairment or dementia presents an opportunity for the dialysis team to engage formally in ACP with patients and their families (see Advance Care Planning section). Families should be provided with ongoing education and counseling around the natural history of dementia and encouraged to identify opportunities and barriers that impact patient safety and quality of life. Frequent meetings to discuss changes and future circumstances under which dialysis discontinuation would be appropriate are necessary. It is important to ensure that families understand dementia as a terminal illness with a limited lifespan. Median life expectancy for nondialysis patients with dementia is approximately half that of age-matched patients; with both dialysis and dementia, this is substantially lower.