Dialysis Associated With Functional Decline, Rise in Caregiver Burden

A recent study has found that the initiation of dialysis in older patients is associated with a decline in functional status and an increase in caregiver burden.

Among older adults starting dialysis, 40% experienced a decline in functional status and the percentage of caregivers reporting a high burden of care increased from 23% to 38% after dialysis initiation.

“We showed that age and frailty were both risk factors for the composite outcome of functional decline and death. Furthermore, we have shown that functional decline in older adults is highly prevalent and is mainly due to a loss of independence in instrumental activities of daily living—activities such as medication intake, laundry, and food preparation,” said Namiko Goto, MD, of the department of geriatrics at University Medical Center Utrecht.

In order to examine the association with the initiation of dialysis with functional decline and caregiver burden, investigators used data from the geriatric assessment in the Older patients starting Dialysis (GOLD) study. Investigators identified 196 patients initiating dialysis, either peritoneal dialysis (PD) and hemodialysis (HD), who were 65 or older from 17 centers across the Netherlands.

After applying inclusion criteria, a cohort of 187 participants were identified for the investigators’ analyses. The mean age of the cohort was 75 and 33% of the participants were women. Among them, the most common causes of ESRD were vascular disease (50%) and diabetes (16%).

All participants were assessed using the Fried Frailty Index and the Groningen Frailty Indicator at the point of dialysis initiation. Participants’ functional status, which was measured by activities of daily life (ADL), their instrumental activities of daily life (IADL), and caregiver burden were assessed at baseline and, again, at 6 months.

Investigators used 3 definitions to assess functional status. Decline was defined as a loss of 1 or more domains in functional status, stable was defined as no difference between baseline and follow-up, and improvement was defined as a gain of 1 or more domains in functional status.

Investigators performed a logistic regression was performed to determine the association between function out come and different potential predictors. Additionally, a univariable analysis was used to assess components of the geriatric assessment.

At baseline, investigators reported that 21% of participants were independent in regard to functional status, 52% were mildly/moderately dependent, and 27% were severely dependent. Investigators noted that severely dependents experienced more symptoms of depression (54% vs. 12%), were more impaired in mobility (56% vs. 0%), and more frail according to frailty assessments (geriatric assessment 96% vs. 24%, Fried frailty index 84% vs. 13%, Groningen Frailty Indicator 92% vs. 39%) compared to the group of independent participants.

At the 6-month follow-up, 8% of participants had died and 2% had received a kidney transplant. Of the patients who remained alive, which includes those who received kidney transplants, 40% experienced a decline in function status. Conversely, 34% of participants remained stable and 18% experienced improvement. Most of the decline in functional status among participants was due to loss in IADL independence. In regard to ADL, most participants (66%) remained stable.

Investigators noted differences between outcomes among the older patients included in the study. Participants in the younger groups were more likely to be categorized as improved or stable (65-69 68%, 70-74 57% and 75 or older 43%).

Among patients 75 and older, almost half (45%) experienced functional decline and 11% of the patients died. Severely dependent patients died more frequently compared to participants in the independent group (0% in the independent group, 9% in the mild/moderate dependent group, 12% in the severely dependent group).

The prevalence of high caregiver burden increased from 23% to 38% and, in the multivariable analysis, investigators found that age and a high Groningen Frailty Indicator score were associated with functional decline and death.

Based on findings, investigators concluded that functional decline within the first 6 months after initiating dialysis is highly prevalent, risk is higher among older and frail patients, and that functional decline was driven by a decline in IADL.

This study, titled “Association of Initiation of Maintenance Dialysis With Functional Status and Caregiver Burden,” is published in the Clinical Journal of the American Society of Nephrology.