Transcript Dialysis_in_the_Elde.. - ANNA Jersey North Chapter 126

Dialysis in the Elderly
Zalman Suldan MD, PhD
Dialysis in the Elderly
What is “Elderly”
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Merriam Webster’s Online Dictionary: Main
Entry: 1el·der·ly
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Pronunciation: \ˈel-dər-lē\
Function: adjective
Date: 1611
1 a : rather old; especially : being past middle age b :
old-fashioned
2 : of, relating to, or characteristic of later life or
elderly persons
◦ — el·der·li·ness noun
Dialysis in the Elderly
What is “Elderly”? - Other definitions
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AARP – Association for the Advancement of Retired
Persons
◦ Can now join at 50 years old
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Social Security (or Medicare!)
◦ Retirement age – 66 years old (will be 67 in
several years)
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Age at which major Medical Issues tend
to start occurring…
◦ 60? 70? 80?
Dialysis in the Elderly
What is “Elderly for Dialysis”
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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
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Other countries?
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United States
◦ USRDS stratification of data:
◦ 45-64 yo; 65-75 yo; 75 yo and above
Dialysis in the Elderly
What is “Elderly for Dialysis”
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Personal feelings:
◦ What do you think?
◦ Have you ever had older family members (or
close friends) who have needed dialysis?
Dialysis in the Elderly
USRDS Data
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In 1980, there were:
 9,206 people 64-75 on dialysis and 2,790 people
>75
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By 1990:
 35,572 (64-75) and 18,304 (>75)
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By 2007:
 102,627 (64-75) and 81,434 (>75) (WOW!)
Dialysis in the Elderly
USRDS Data
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In 1980, there were:
 273.4 people per million >75yo
 289.2 people per million total population
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By 1990:
 1,603.9 people per million >75yo
 807.30 people per million total population
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By 2007:
 5,124.1 people per million >75yo
 1664.90 people per million total population
Dialysis in the Elderly
USRDS Data
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Between 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 Elderly
USRDS Data
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What does this mean???
Dialysis in the Elderly
USRDS Data
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What does this mean???
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Dialysis in the Elderly is an important
topic to discuss!
Dialysis in the Elderly
USRDS Data
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What does this mean???
Dialysis in the Elderly
USRDS Data
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What does this mean???
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Dialysis in the Elderly is a topic that
NEEDS TO BE DISCUSSED!
Dialysis in the Elderly
USRDS Data
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Average 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 Elderly
USRDS Data
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Average life expectancy on dialysis:
◦ Patient > 75yo: approximately 4 ½ years
(Nephsap January 2010)
◦ Woman > 65yo with diabetes: 2 years (CanUSA
study data)
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Case of Mrs. A.
Case Studies I – Mrs. F.
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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.
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Mr. A. is:
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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
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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.
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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. N
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Mrs. F. is:
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◦ 94 years old
◦ Lives in an independent living
apartment with her husband
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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
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for her many doctor
appointments
Mr. A. is:
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Mr. N. 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
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Has had a constant battle
between aggressive diuresis
for optimization of cardiopulmonary function and less
aggressive diuresis to protect
renal function
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Is too high risk for the OR
for even an AV Fistula
Has pruritis, loss of appetite,
occasional nausea
◦
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
Compare also with Mr. H.:
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has severely compromised
systolic function (EF 17%)
is unable to even stand up
from bed without becoming
short of breath
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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)
Dialysis in the Elderly
What 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
Dialysis in the Elderly
What can be gained/lost with dialysis?
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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 Elderly
What 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)
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◦ 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
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Dialysis in the Elderly
More Issues for the Elderly in Particular
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Access difficulties
◦ Ability to get an AV Fistula
 Surgical risk
 Poor Vascular Candidates
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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 Elderly
More Issues for the Elderly in Particular
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Ability to do other forms of dialysis?
◦ PD, home hemodialysis
◦ Decreased dexterity, sophistication with
technology, machines
◦ Lack of partner/caregiver able to help
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Malnutrition
Suitability for transplant
Dialysis may force person from their home
due to increase in level of care requirement
(sometime to nursing home level)
The Elephant in the Room
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What are the ethical issues involved in
dialysis in the elderly?
The Elephant in the Room
Ethical Issues
Futility of Care
 Determining the wishes of a patient
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◦ Especially if dementia is present
Balancing Family concerns with patient’s
wishes
 Financial concerns of Families
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◦ Taxes and the tax year of death
◦ Continuation of family pension benefits while
patient remains alive
◦ Etc…
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.
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Would Mrs. F benefit from dialysis?
Case Studies II – Mr. A.
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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
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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.
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Would Mr. A. benefit from dialysis?
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Would Mr. H. benefit from dialysis?
Case Studies III – Mr. N.
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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.
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Would Mr. N. benefit from dialysis?
Other issues… regulatory issues
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New CMS/Medicare push as of 20102011 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 issues
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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
Other issues… regulatory issues
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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
What is needed?
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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?
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Be quick to dialyze when appropriate
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Be slow to dialyze when appropriate
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
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