Hemodialysis initiation can lead to significant functional and cognitive decline in older adults.
A continually progressing healthcare landscape has resulted in older patients undergoing treatment protocols that originally targeted a much younger patient demographic. For example, this shift in typical treatment age has been documented in patients undergoing dialysis treatment for end-stage kidney disease (ESKD).
Andrew Davenport, MD, and his colleagues, including Priyanka Khatri, MBBS, recently examined the impact of age on the administration and side effects of traditional dialytic targets in patients undergoing ESKD treatment. The findings of this analysis were published in the Journal of Nephrology. Dr. Khatri spoke with Physician’s Weekly and shared her insights on the review’s findings.
When asked about the necessity of this exploration, Dr. Khatri says, “The demographics of the end-stage kidney disease population are changing, especially in developed countries with a greater number of older adults with greater co-morbidity and frailty now being offered kidney replacement therapy. Hemodialysis initiation can lead to significant functional and cognitive decline in older adults.”
Adjusting Protocols
Dr. Khatri clarifies, “Thus, more careful attention to the hemodialysis prescription and treatment frequency is needed in this elderly patient group, aiming to preserve residual kidney function and prevent some of the detrimental effects associated with the standard paradigm of thrice weekly four-hour hemodialysis sessions. This is the reason we decided to explore this topic further and review the current evidence to guide clinicians in day-to-day practice in their management of hemodialysis in older adults.”
Patients’ metabolic rate, activity level, and muscle mass decline as they age. In addition, their frailty level and comorbidities increase while thirst drive and appetite decrease. The result is a reduction in the generation of uremic toxins, which tends to indicate a reduced need for dialysis doses.
When asked about applying the findings of the review, Dr. Khatri shares, “We recommend an algorithm that can be easily incorporated into day-to-day practice by dialysis units. This algorithm guides the managing team regarding monitoring of a patient on incremental dialysis even in the absence of 24-hour urinary collections, which are especially cumbersome in frail elderly patients.”
Older Patient Needs
Individualized care for older adults undergoing dialysis is a key component in improving care and optimizing results, according to the findings of the review. Dialysis prescriptions should be tailored to a patient’s clinical condition, functional status, physical capabilities, comorbidities, stage of life, and personal preferences.
The review also addressed vascular access concerning the common fistula first protocol in dialysis administration. Dr. Khatri and Prof. Davenport caution in their review that there may be better practices for older adults. Instead, they recommend an individualized approach to vascular access, which takes into consideration patient preference, quality of life, pain, life expectancy, and comorbidities.
Dr. Khatri highlights the urgency of this issue, “The rising numbers of older adults undergoing dialysis worldwide make this a topic of particular interest to the healthcare community.”
As for future exploration of individualized dialysis management for older patients, Prof. Davenport and Dr. Khatri believe, “Future research needs to focus on the effects of incremental dialysis on cognition and residual kidney function in older adults.”
