Rehabilitation of the elderly patient on dialysis

Impact of the Karnofsky Performance Status on Survival and its Dynamics during the Terminal Year of Peritoneal Dialysis Patients

Background

Simple and low-cost tools to monitor the risk profile of patients on peritoneal dialysis (PD) at high risk of complications and mortality are scarce. One of the tools available to monitor the variation in vitality and dependence levels is the Karnofsky performance status (KPS). This study analyzed the average trends and variation of KPS during the 12 months before death and its independent value in predicting patients’ survival.

Methods

The data were compiled from the BRAZPD II multi-center study, performed in Brazil between 2004 and 2011. For the analysis of KPS dynamics, we included patients with at least 12 months of follow-up on PD and who had a fatal event during the follow-up. The following covariables were evaluated: age, gender, ethnicity, educational level, and presence of diabetes. We used the linear regression model to present the results: the log (time) before death was represented by the regression variable and KPS was the response. We also analyzed the independent impact of baseline KPS on patients’ survival.

Results

From the population of 9,905 patients enrolled in the BRAZPD study, 4,133 survived 12 months on PD and were included in the analysis. There was a gradual decline in the KPS scores, which accelerated in the last 2 months before death. These changes were similar irrespective of age, race, family income, gender, diabetes, PD modality, and education level. We observed 989 fatal events in this population during the observation period, and the KPS score was identified as an independent predictor for mortality in this cohort.

Conclusions

This study demonstrates for the first time the dynamics of KPS before death in PD patients, indicating a progressive and accelerated decline of KPS in the 12 months before patients died. In addition, KPS was an independent predictor of mortality in this population.

Quality of life in end-stage renal disease patients

Health-related quality of life (QOL) refers to the measure of a patient's functioning, well-being, and general health perception in each of three domains: physical, psychological, and social. Along with survival and other types of clinical outcomes, patient QOL is an important indicator of the effectiveness of the medical care they receive. QOL of patients with end-stage renal disease is influenced by the disease itself and by the type of replacement therapy. Numerous studies have identified the effect of such factors as anemia, age, comorbidity, and depression on QOL. Most of these factors appear during the predialysis period, and the adequate management of some of them could influence patient outcomes. Among replacement therapies, transplantation appears to give the best QOL for large groups of patients. No conclusive data exist to prove differences in QOL between hemodialysis patients and peritoneal dialysis patients. In the case of elderly patients or those with a high degree of comorbidity, the best treatment option should be assessed in each individual case, taking all possible factors into account. Finally, it has been proven that physical and mental function are inversely correlated with the risk for hospitalization and mortality.

Quality of life in end-stage renal disease patients

Health-related quality of life (QOL) refers to the measure of a patient's functioning, well-being, and general health perception in each of three domains: physical, psychological, and social. Along with survival and other types of clinical outcomes, patient QOL is an important indicator of the effectiveness of the medical care they receive. QOL of patients with end-stage renal disease is influenced by the disease itself and by the type of replacement therapy. Numerous studies have identified the effect of such factors as anemia, age, comorbidity, and depression on QOL. Most of these factors appear during the predialysis period, and the adequate management of some of them could influence patient outcomes. Among replacement therapies, transplantation appears to give the best QOL for large groups of patients. No conclusive data exist to prove differences in QOL between hemodialysis patients and peritoneal dialysis patients. In the case of elderly patients or those with a high degree of comorbidity, the best treatment option should be assessed in each individual case, taking all possible factors into account. Finally, it has been proven that physical and mental function are inversely correlated with the risk for hospitalization and mortality.

Functional impairment, depression, and life satisfaction among older hemodialysis patients and age-matched controls: a prospective study

OBJECTIVE

To compare change over time in functional impairment, depression, and life satisfaction among older dialysis patients and age-matched controls.

DESIGN

Prospective cohort study over 3 years.

SETTING

Urban and rural communities throughout Georgia.

SUBJECTS

One hundred thirteen prevalent renal failure patients on in-center hemodialysis and 286 controls.

MAIN OUTCOME MEASURES

Ordinal functional impairment index and life satisfaction rating, and Center for Epidemiologic Studies Depression Scale.

RESULTS

Dialysis patients, compared with controls, reported significantly more functional impairment at baseline, and also at follow-up after adjusting for baseline impairment and covariates. Dialysis patients had higher depression scores at baseline, and also at follow-up after adjusting for baseline depression and covariates. In contrast, dialysis patients reported lower life satisfaction at baseline than did controls, but the two cohorts were not significantly different on reported life satisfaction at follow-up, after adjusting for baseline life satisfaction and race. In both cohorts, functional impairment and depression were significantly related.

CONCLUSION

Older dialysis patients' life satisfaction at a 3-year follow-up, which was similar to life satisfaction among age-matched controls, indicates the value of delivered dialysis care; the value of this care would be increased by reducing excess functional impairment in these patients.

Self-reported functional status: an important predictor of health outcomes among end-stage renal disease patients

A contemporary focus on outcomes assessment has provided affirmation that patient functional status is both an important outcome of medical care and an important predictor of longer term outcomes such as morbidity and/or mortality. Monitoring functional status among end-stage renal disease (ESRD) patients is particularly critical because the cycle of physical deconditioning experienced by renal patients is both insidious and malignant. Over the past several years, patient self-report instruments have been used with increasing frequency to assess functioning. Among ESRD patients, such self-reports have reliably predicted mortality and some morbidity. Additionally, renal patients' self-reported functioning is also correlated with the results of several commonly performed laboratory tests. Based on these findings, measures of self-reported functional status might be considered a practical adjunct to regular patient assessments. They could be routinely used for purposes that might include: identifying the particular areas of functioning and well-being that need improvement; screening for subtle changes in health status; establishing physical status baselines; and corroborating the effectiveness of physical activity interventions. Overall, ESRD patients' self-report of their functioning appears to secure, synthesize, and standardize data about patient health status that is unavailable through any other mechanism. Such information may be essential to medicine's primary missions of promoting health and preserving life.