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The Relevance of Geriatric Impairments in Patients Starting Dialysis: A Systematic Review.

ABSTRACT: With aging of the general population, patients who enter dialysis therapy will more frequently have geriatric impairments and a considerable comorbidity burden. The most vulnerable among these patients might benefit from conservative therapy. Whether assessment of geriatric impairments would contribute to the decision-making process of dialysis initiation is unknown.A systematic Medline and Embase search was performed on December 1, 2015 to identify studies assessing the association between risk of mortality or hospitalization and one or more geriatric impairments at the start of dialysis therapy, including impairment of cognitive function, mood, performance status or (instrumental) activities of daily living, mobility (including falls), social environment, or nutritional status.Twenty-seven studies were identified that assessed one or more geriatric impairments with respect to prognosis. The quality of most studies was moderate. Only seven studies carried out an analysis of elderly patients (?70 years old). Malnutrition and frailty were systematically assessed, and their relation with mortality was clear. In addition, cognitive impairment and functional outcomes at the initiation of dialysis were related to an increased mortality in most studies. However, not all studies applied systematic assessment tools, thereby potentially missing relevant impairment. None of the studies applied a geriatric assessment across multiple domains.Geriatric impairment across multiple domains at dialysis initiation is related to poor outcome. However, information in the elderly is sparse, and a systematic approach of multiple domains with respect to poor outcome has not been performed. Because a geriatric assessment has proved useful in predicting outcome in other medical fields, its potential role in the ESRD population should be the subject of future research.

SUBMITTER: van Loon IN

PROVIDER: S-EPMC4934838 | biostudies-other | 2016 Jul

REPOSITORIES: biostudies-other

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The Relevance of Geriatric Impairments in Patients Starting Dialysis: A Systematic Review.

van Loon Ismay N IN Wouters Tom R TR Boereboom Franciscus T J FTJ Bots Michiel L ML Verhaar Marianne C MC Hamaker Marije E ME

Clinical journal of the American Society of Nephrology : CJASN 20160426 7

<h4>Background and objectives</h4>With aging of the general population, patients who enter dialysis therapy will more frequently have geriatric impairments and a considerable comorbidity burden. The most vulnerable among these patients might benefit from conservative therapy. Whether assessment of geriatric impairments would contribute to the decision-making process of dialysis initiation is unknown.<h4>Design, setting, participants, & measurements</h4>A systematic Medline and Embase search was ...[more]

PMID: 27117581

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Project description:BACKGROUND:Maximal conservative management (MCM) may be an appropriate alternative option for dialysis in some elderly patients with end-stage kidney disease (ESKD). Evidence about the impact of dialysis or MCM on quality of life (QoL) in older patients is sparse. In the GOLD (Geriatric assessment in OLder patients starting Dialysis) Study the trajectory of QoL was assessed in patients starting dialysis or MCM. METHODS:Patients ≥65 years old were included just prior to dialysis initiation or after decision for MCM. Baseline data included demographics, frailty as measured with a geriatric assessment, comorbidity (CIRS-G) and QoL, measured with the EQ-5D-3 L (EQ-5D Index and overall self-rated health). Six months follow-up data included QoL, hospitalizations and mortality. Change of QoL was assed with paired t-tests. Cox-regression was used to assess survival of MCM and dialysis patients. RESULTS:The cohort comprised 192 dialysis and 89 MCM patients. The MCM patients were older (mean age 82 ± 6 vs. 75 ± 7 years, p < 0.01) and mean kidney function was better (eGFR 11.5 ± 4.0 vs. 8.0 ± 2.9 ml/min/1.73m2, p < 0.01). Baseline QoL did not differ significantly between the groups. After six months, EQ-5D Index did not improve significantly in the dialysis group with mean ± standard error (SE) 0.026 ± 0.014 (p = 0.10; not clinically relevant), but a small but clinically relevant decline was seen in the conservative group: 0.047 ± 0.022 (p < 0.01; between group difference p < 0.01). Hospitalization occurred in 50% of dialysis patients vs. 24% of conservative patients (p < 0.01). In patients over 80 years old, no survival benefit could be found for dialysis patients starting dialysis vs. MCM. CONCLUSION:A small decline of QoL was found for conservative patients, while QoL did not change in dialysis patients. However, hospitalization rate was higher in patients starting dialysis. In patients over 80 years, no survival benefit was found.

Project description:The aim of this systematic review is to give an update of all currently available evidence on the relevance of a geriatric assessment in the treatment of older patients with hematologic malignancies. A systematic search in MEDLINE and EMBASE was performed to find studies in which a geriatric assessment was used to detect impaired geriatric domains or to address the association between geriatric assessment and survival or clinical outcome measures. The literature search included 4,629 reports, of which 54 publications from 44 studies were included. Seventy-three percent of the studies were published in the last 5 years. The median age of the patients was 73 years (range, 58-86) and 71% had a good World Health Organization (WHO) performance status. The median prevalence of geriatric impairments varied between 17% and 68%, even in patients with a good WHO performance status. Polypharmacy, nutritional status and instrumental activities of daily living were most frequently impaired. Whereas several geriatric impairments and frailty (based on a frailty screening tool or summarized geriatric assessment score) were predictive for a shorter overall survival, WHO performance status lost its predictive value in most studies. The association between geriatric impairments and treatment-related toxicity varied, with a trend towards a higher risk of (non-)hematologic toxicity in frail patients. During the follow-up, frailty seemed to be associated with treatment non-completion, especially when patients were malnourished. Patients with a good physical capacity had a shorter stay in hospital and a lower rate of hospitalization. Geriatric assessment, even in patients with a good performance status, can detect impaired geriatric domains and these impairments may be predictive of mortality. Moreover, geriatric impairments suggest a higher risk of treatment-related toxicity, treatment non-completion and use of healthcare services. A geriatric assessment should be considered before starting treatment in older patients with hematologic malignancies.

Project description:Chronic kidney disease is associated with an increased risk of fracture and cardiovascular mortality. The risk of fracture in hemodialysis (HD), peritoneal dialysis (PD) and kidney transplant (KT) patients is higher when compared with the general population. However, there exists a knowledge gap concerning which group has the highest risk of fracture. We aimed to compare the risk of fracture in HD, PD, and KT populations. We conducted a systematic review of observational studies evaluating the risk of fracture in HD, PD, or KT patients. Eligible studies were searched using MEDLINE, Embase, Web of Science, and Cochrane Library from their inception to January 2016, and in grey literature. Incidences (cumulative and rate) of fracture were described together using the median, according to fracture sites, the data source (administrative database or cohort and clinical registry), and fracture diagnosis method. Prevalence estimates were described separately. We included 47 studies evaluating the risk of fracture in HD, PD, and KT populations. In administrative database studies, incidence of hip fracture in HD (median 11.45 per 1000 person-years [p-y]), range: 9.3 to 13.6 was higher than in KT (median 2.6 per 1000 p-y; range 1.5 to 3.8) or in PD (median 5.2 per 1000 p-y; range 4.1 to 6.3). In dialysis (HD+PD), three studies reported a higher incidence of hip fracture than in KT. Prevalent vertebral fracture (assessed by X-rays or questionnaire) reported in HD was in a similar range as that reported in KT. Incidence of overall fracture was similar in HD and KT, from administrative databases studies, but lower in HD compared with KT, from cohorts or clinical registry studies. This systematic review suggests an important difference in fracture risk between HD, PD, and KT population, which vary according to the diagnosis method for fracture identification. © 2018 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Project description:BackgroundThe elderly population is highly susceptible to develop post-operative complications after major surgeries. It is not clear whether the comprehensive geriatric care models are effective in reducing adverse events. The objective of this systematic review and meta-analysis is to determine whether the comprehensive geriatric care models improved clinical outcomes, particularly in decreasing the prevalence of delirium and length of hospital stay (LOS) in elderly surgical patients.MethodWe searched Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Emcare Nursing, Web of Science, Scopus, CINAHL, ClinicalTrials. Gov, and ICTRP between 2009 to January 23, 2020. We included studies on geriatric care models in elderly patients (≥60 years) undergoing elective, non-cardiac high-risk surgery. The outcomes were the prevalence of delirium, LOS, rates of 30-days readmission, and 30-days mortality. We used the Cochrane Review Manager Version 5.3. to estimate the pooled Odds Ratio (OR) and Mean Difference (MD) using random effect model analysis.ResultsEleven studies were included with 2672 patients [Randomized Controlled Trials (RCTs): 4; Non-Randomized Controlled Trials (Non-RCTs): 7]. Data pooled from six studies showed that there was no significant difference in the prevalence of delirium between the intervention and control groups: 13.8% vs 15.9% (OR: 0.76; 95% CI: 0.30-1.96; p = 0.57). Similarly, there were no significant differences in the LOS (MD: -0.55; 95% CI: - 2.28, 1.18; p = 0.53), 30-day readmission (12.1% vs. 14.3%; OR: 1.09; 95% CI: 0.67-1.77; p = 0.73), and 30-day mortality (3.2% vs. 2.1%; OR: 1.34; 95% CI: 0.66-2.69; p = 0.42). The quality of evidence was very low.ConclusionsThe geriatric care models involved pre-operative comprehensive geriatric assessment, and intervention tools to address cognition, frailty, and functional status. In non-cardiac high-risk surgeries, these care models did not show any significant difference in the prevalence of delirium, LOS, 30-days readmission rates, and 30-day mortality in geriatric patients. Further RCTs are warranted to evaluate these models on the postoperative outcomes.Trial registrationPROSPERO registration number - CRD42020181779 .

Dataset Information

The Relevance of Geriatric Impairments in Patients Starting Dialysis: A Systematic Review.

Publications

The Relevance of Geriatric Impairments in Patients Starting Dialysis: A Systematic Review.

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