Clinical implications of geriatric impairments in chronic kidney disease: Frailty, falls, fractures and functional decline

Abstract

The chronic kidney disease population is aging. Currently, more than half of the patients with end-stage kidney disease (ESKD) in the Netherlands are 65 years or older. As patients age, geriatric impairments, such as frailty, falls, functional dependence and cognitive impairment, become more prevalent. Nevertheless, there is high variance between patients, ranging from no geriatric impairment to accumulation of multiple deficits. Subsequently, the prevalence of these impairments may potentially influence prognosis and may therefore facilitate the decision-making process regarding the start of dialysis. In this thesis, we assessed the prevalence and course of geriatric impairments and their relation with outcome in patients with chronic kidney disease. The main results of this thesis are that geriatric impairments are highly prevalent in elderly patients with ESKD. Interestingly, also in a younger relatively fit ESKD population and in elderly patients with milder stages of chronic kidney disease, problems such as accidental falls and vertebral fractures are more prevalent than in the general population. We showed that the presence and accumulation of various geriatric impairments was related to functional decline, mortality and hospitalizations. Furthermore, we demonstrated that especially in frail older adults the initiation of dialysis was frequently accompanied by functional decline or death within 6 months after start of dialysis. In addition, the initiation of dialysis seems to be accompanied by an increase of caregiver burden. As frailty screening tools are inadequate to discriminate frail from non-frail patients and geriatric impairments may potentially be missed, it is recommended to use a geriatric assessment to assess the health status of the elderly patient. A regularly (e.g. yearly, or when major events occur) performed (standardized) geriatric assessment may be beneficial to ensure a timely diagnosis of issues that are potentially modifiable or can influence treatment decisions and care provision. Considering it may facilitate decision-making regarding dialysis and could potentially help with optimization, it is recommended to perform this assessment from the predialysis phase in close cooperation with a geriatrician.