Chronic kidney disease in the elderly

Chapter 22 Chronic kidney disease in the elderly


Since the early 1990s, at least 45% of new patients entering the end-stage renal disease (ESRD) program in the U.S. each year have been more than 65 years old. This percentage is increasing; the figure for 2007 was 49%. The same trend appears in dialysis programs all over the world. Regardless of the treatment modality selected, some changes are required to adapt the therapy to the special needs of geriatric patients. As will become clear during the course of this chapter, besides presenting some limitations, older adult patients bring certain assets to their treatment regimens. All maintenance dialysis treatment modalities are available to the older adult patient, subject to the usual considerations, such as adequate vascular access or an intact peritoneal membrane.




Are the causes of chronic kidney disease different in elderly patients?


Not really. The most common cause is nephrosclerosis secondary to either diabetes or hypertension. Causes such as chronic glomerulonephritis and pyelonephritis are as common in older patients as in younger patients, although there may be slightly more older adult patients with an “unknown” renal diagnosis (biopsies are rarely done in elderly patients with renal failure of undetermined cause).



How do older patients differ from younger chronic kidney disease patients?


Comorbid conditions are much more common in older patients and can complicate the treatment of chronic kidney disease (CKD). Examples of significant comorbidities include an impaired cardiovascular system, osteoporosis, type 2 diabetes, delayed protein synthesis, reduced protein intake, impaired pulmonary function, impaired cognitive function, poor vision, poor mobility, and poor coordination.


Although not physical factors, adverse psychosocial and socioeconomic factors complicate treatment regimens for a larger proportion of older patients than younger patients.



Can elderly patients benefit from renal replacement therapy?


Many, perhaps most, elderly people can benefit from renal replacement therapy, often returning to a level of physical functioning and quality of life that is either equivalent to that of people their age without CKD or at least acceptable to the patient.


Some patients, usually but not necessarily elderly, may not benefit from treatment. Examples include those with irreversible dementia or extremely debilitating or imminently terminal comorbid conditions, such as cancer or advanced congestive heart failure. However, there are few firm medical or community standards with respect to withholding treatment, and decisions regarding initiating therapy vary with individual physicians or family members.



What is trial dialysis?


The concept of trial dialysis is gaining favor in some areas. A patient for whom the value of therapy is questionable may be given treatment (usually hemodialysis) for a clearly defined period to see whether explicitly described clinical goals can be achieved. Examples of such patients might include those with unexplained dementia, potentially reversible acute kidney injury, unexplained worsening of congestive heart failure, personality change, and adult failure-to-thrive syndrome. The duration of treatment, specific goals, and subsequent actions (continue or discontinue) are agreed to in advance by the medical team, family, and, in some cases, the patient. This allows the patient every opportunity to benefit from treatment, if that is possible; if it is not, trial dialysis provides the family and patient with time to adjust and the knowledge that every effort was made.



Can elderly patients be successfully transplanted?


Although the proportion of older adult CKD patients who qualify for transplantation is not as high as that of younger patients, graft survival in those who do receive transplants is about the same. Kidneys are becoming more available to elderly recipients because some transplant surgeons believe that organs donated by an older person should go to an older person. Elderly patients often require less intensive immunosuppressive therapy, due to the fact that their immune systems may already be compromised by age.


Although older adult patient survival is not as good as that of younger patients, because of an increased number and severity of complications, data show satisfactory results for transplantation in elderly patients. By the same token, dialysis is also safer than ever for the elderly, so making a decision between modes of therapy is not simple.



What are the advantages of peritoneal dialysis for elderly patients?


Peritoneal dialysis (PD), unlike hemodialysis at the present time, is a home dialysis therapy. Patients benefit from being at home in a number of ways. First, they are spared the considerable time, effort, and expense of being transported to and from a dialysis center. The transportation effort is, in itself, very debilitating for some older patients. Second, home dialysis patients are in full charge of administering their own therapy. This not only fosters independence but also preserves their usual lifestyle, allowing patients to perform exchanges at their convenience, within reason, rather than requiring them to conform to a rigid in-center schedule.


Patients on PD do not need a vascular access, with its attendant problems (although they must have a peritoneal access catheter, with its attendant problems), and many elderly patients have inadequate peripheral vessels. Because PD is a continuous—or at least daily—therapy, blood chemistries and fluid status approach a steady state; thus PD patients do not suffer the effects of the rapid biochemical and fluid changes common in hemodialysis. This can be a significant advantage because elderly patients are more prone to adverse reactions to these changes. For example, PD patients with diminished cardiac reserve experience less orthostatic hypotension or other cardiac symptoms in response to fluid removal. Slow, continuous therapy allows better correction of brain electrophysiologic and cognitive function abnormalities, which incurs less risk of destabilizing the fragile mental equilibrium of some elderly patients.


Another advantage of daily therapy is that dietary and fluid restrictions are less rigid, which can be important for those with diminished appetites or impatience with restrictions.

< div class='tao-gold-member'>

Related posts:

  1. Anticoagulation and heparin administration
  2. Pediatric hemodialysis
  3. Management of quality in dialysis care
  4. Acute kidney injury and dialysis

Stay updated, free articles. Join our Telegram channel
Tags:
Jul 24, 2016 | Posted by in NURSING | Comments Off on Chronic kidney disease in the elderly

Full access? Get Clinical Tree
Get Clinical Tree app for offline access