Dialysis in the Elderly

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