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Voorend CGN, van Buren M, Berkhout-Byrne NC, Kerckhoffs APM, van Oevelen M, Gussekloo J, Richard E, Bos WJW, Mooijaart SP. Apathy Symptoms, Physical and Cognitive Function, Health-Related Quality of Life, and Mortality in Older Patients With CKD: A Longitudinal Observational Study. Am J Kidney Dis 2024; 83:162-172.e1. [PMID: 37741610 DOI: 10.1053/j.ajkd.2023.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 07/14/2023] [Accepted: 07/24/2023] [Indexed: 09/25/2023]
Abstract
RATIONALE & OBJECTIVE Apathy reflects diminished motivation, goal-directed behavior, and emotions, as well as less engagement in social interactions. Apathy overlaps with depression and is associated with cognitive decline. In the older individuals with chronic kidney disease (CKD), both depression and cognitive impairments are common, but apathy symptoms have been underreported. We investigated the occurrence of apathy symptoms and their associations with physical and cognitive functioning, health-related quality of life (HRQoL), and mortality in older patients with CKD. STUDY DESIGN Prospective observational cohort study. SETTING & PARTICIPANTS 180 outpatients aged≥65 years with estimated glomerular filtration rate≤20mL/min/1.73m2 from 5 Dutch nephrology centers. EXPOSURE Apathy symptoms at baseline were considered present when a Geriatric Depression Scale's 3-item apathy subscale score was≥2 points. OUTCOME Physical and cognitive functioning, HRQoL (assessed in annual geriatric assessments), and 4-year mortality. ANALYTICAL APPROACH Linear regression for cross-sectional associations, linear regression models for longitudinal associations, and Cox regression models for mortality over 4 years of observation. RESULTS Apathy symptoms were present in 64 patients (36%; 67% men; median age 75.5 years), of whom 32 (50%) had no depressive symptoms. At baseline, the presence of apathy symptoms was associated with significantly more frailty, more functional dependence, less physical capacity, lower visuoconstructive performance, worse delayed recall, and lower HRQoL scores. The presence of apathy symptoms at baseline was also associated with a higher mortality risk (hazard ratio, 2.3 [95% CI, 1.3-4.2], P=0.005 adjusted for age, sex, and high education level), but not with changes in physical and cognitive functioning or HRQoL during the follow-up period. LIMITATIONS Risk of selection bias and residual confounding. CONCLUSIONS Apathy symptoms were highly prevalent and associated with concurrent lower physical and cognitive status, lower HRQoL, and increased mortality. These findings highlight apathy as a potentially important clinical phenotype in older CKD patients. PLAIN-LANGUAGE SUMMARY We observed that older kidney patients often present apathy symptoms, such as less motivation, fewer goal-directed behaviors, fewer emotions, and less social engagement. Prior research has not extensively described apathy in kidney disease. We investigated the link between apathy symptoms and poor outcomes. We measured physical functioning, cognitive functioning, and quality of life. We learned that one-third of our older kidney patients showed symptoms of apathy, only half of whom had symptoms of depression. Patients with apathy symptoms showed lower quality of life and lower physical and cognitive performance. They also had a higher risk of death. These findings highlight the need for awareness of apathy symptoms in older kidney patients.
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Affiliation(s)
- Carlijn G N Voorend
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, the Netherlands.
| | - Marjolijn van Buren
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, the Netherlands; Department of Internal Medicine, Haga Hospital, The Hague, the Netherlands
| | - Noeleen C Berkhout-Byrne
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, the Netherlands
| | - Angèle P M Kerckhoffs
- Department of Internal Medicine and Geriatrics, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - Mathijs van Oevelen
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, the Netherlands
| | - Jacobijn Gussekloo
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands; Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
| | - Edo Richard
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, the Netherlands; Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, the Netherlands
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van Oevelen M, Abrahams AC, Bos WJW, Hoekstra T, Hemmelder MH, ten Dam M, van Buren M. Dialysis withdrawal in The Netherlands between 2000 and 2019: time trends, risk factors and centre variation. Nephrol Dial Transplant 2021; 36:2112-2119. [PMID: 34390576 PMCID: PMC8577625 DOI: 10.1093/ndt/gfab244] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Dialysis withdrawal is a common cause of death in dialysis-dependent patients. This study aims to describe dialysis withdrawal practice in The Netherlands, focussing on time trends, risk factors and centre variation. METHODS Data were retrieved from the Dutch registry of kidney replacement therapy patients. All patients who started maintenance dialysis and died in the period 2000-2019 were included. The main outcome was death after dialysis withdrawal; all other causes of death were used for comparison. Time trends were analysed as unadjusted data (proportion per year) and the year of death was included in a multivariable logistic model. Univariable and multivariable analyses were performed to identify factors associated with withdrawal. Centre variation was compared using funnel plots. RESULTS A total of 34 692 patients started dialysis and 18 412 patients died while on dialysis. Dialysis withdrawal was an increasingly common cause of death, increasing from 18.3% in 2000-2004 to 26.8% in 2015-2019. Of all patients withdrawing, 26.1% discontinued treatment within their first year. In multivariable analysis, increasing age, female sex, haemodialysis as a treatment modality and year of death were independent factors associated with death after dialysis withdrawal. Centre variation was large (80.7 and 57.4% within 95% control limits of the funnel plots for 2000-2009 and 2010-2019, respectively), even after adjustment for confounding factors. CONCLUSIONS Treatment withdrawal has become the main cause of death among dialysis-dependent patients in The Netherlands, with large variations between centres. These findings emphasize the need for timely advance care planning and improving the shared decision-making process on choosing dialysis or conservative care.
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Affiliation(s)
- Mathijs van Oevelen
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Alferso C Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Tiny Hoekstra
- Dutch Renal Registry (RENINE), Nefrovisie Foundation, Utrecht, The Netherlands
- Department of Nephrology, Amsterdam University Medical Center–Vrije Universiteit, Amsterdam, The Netherlands
| | - Marc H Hemmelder
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marc ten Dam
- Dutch Renal Registry (RENINE), Nefrovisie Foundation, Utrecht, The Netherlands
- Department of Internal Medicine, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Marjolijn van Buren
- Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Haga Hospital, The Hague, The Netherlands
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Voorend CGN, Joosten H, Berkhout-Byrne NC, Diepenbroek A, Franssen CFM, Bos WJW, Van Buren M, Mooijaart SP. Design of a consensus-based geriatric assessment tailored for older chronic kidney disease patients: results of a pragmatic approach. Eur Geriatr Med 2021; 12:931-942. [PMID: 33871790 PMCID: PMC8463384 DOI: 10.1007/s41999-021-00498-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/08/2021] [Indexed: 12/15/2022]
Abstract
Aim To propose a consensus-based geriatric assessment for optimizing both routine care and research in older patients with advanced chronic kidney disease. Findings Using a pragmatic approach, we reached consensus on a suitable nephrology-tailored geriatric assessment to routinely identify major geriatric impairments in older patients with advanced chronic kidney disease. This geriatric assessment contains instruments in functional, cognitive, psychological, somatic, patient preferences, nutritional status, and social domains, and can be administered with patient questionnaires and professional-administered instruments by nurse (practitioners) in approximately 20 and 40 minutes, respectively. Message We propose a consensus test set for standardized nephrology-tailored geriatric assessment, which is currently being implemented in multiple hospitals and studies, to benefit clinical care for older patients with advanced chronic kidney disease and enhance research comparability. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00498-0. Purpose Unidentified cognitive decline and other geriatric impairments are prevalent in older patients with advanced chronic kidney disease (CKD). Despite guideline recommendation of geriatric evaluation, routine geriatric assessment is not common in these patients. While high burden of vascular disease and existing pre-dialysis care pathways mandate a tailored geriatric assessment, no consensus exists on which instruments are most suitable in this population to identify geriatric impairments. Therefore, the aim of this study was to propose a geriatric assessment, based on multidisciplinary consensus, to routinely identify major geriatric impairments in older people with advanced CKD. Methods A pragmatic approach was chosen, which included focus groups, literature review, inventory of current practices, an expert consensus meeting, and pilot testing. In preparation of the consensus meeting, we composed a project team and an expert panel (n = 33), drafted selection criteria for the selection of instruments, and assessed potential instruments for the geriatric assessment. Results Selection criteria related to general geriatric domains, clinical relevance, feasibility, and duration of the assessment. The consensus-assessment contains instruments in functional, cognitive, psychological, somatic, patient preferences, nutritional status, and social domains. Administration of (seven) patient questionnaires and (ten) professional-administered instruments, by nurse (practitioners), takes estimated 20 and 40 min, respectively. Results are discussed in a multidisciplinary meeting including at least nephrology and geriatric expertise, informing nephrology treatment decisions, and follow-up interventions among which comprehensive geriatric assessment. Conclusion This first multidisciplinary consensus on nephrology-tailored geriatric assessment intent to benefit clinical care and enhance research comparability for older patients with advanced CKD. Supplementary Information The online version contains supplementary material available at 10.1007/s41999-021-00498-0.
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Affiliation(s)
- Carlijn G N Voorend
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands.
| | - Hanneke Joosten
- Department of Internal Medicine, Division of General Internal Medicine, Section Geriatric Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Noeleen C Berkhout-Byrne
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
| | - Adry Diepenbroek
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Casper F M Franssen
- Department of Nephrology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Willem Jan W Bos
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, St. Antonius hospital, Nieuwegein, The Netherlands
| | - Marjolijn Van Buren
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
- Department of Nephrology, Haga Hospital, The Hague, The Netherlands
| | - Simon P Mooijaart
- Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
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Bijkerk R, Kallenberg MH, Zijlstra LE, van den Berg BM, de Bresser J, Hammer S, Bron EE, Achterberg H, van Buchem MA, Berkhout-Byrne NC, Bos WJW, van Heemst D, Rabelink TJ, van Zonneveld AJ, van Buren M, Mooijaart S. Circulating angiopoietin-2 and angiogenic microRNAs associate with cerebral small vessel disease and cognitive decline in older patients reaching end stage renal disease. Nephrol Dial Transplant 2020; 37:498-506. [PMID: 33355649 DOI: 10.1093/ndt/gfaa370] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The prevalence of end-stage renal disease (ESRD) is increasing worldwide, with the majority of new ESRD cases diagnosed in patients aged >60 years. These older patients are at increased risk for impaired cognitive functioning, potentially through cerebral small vessel disease (SVD). Novel markers of vascular integrity may be of clinical value for identifying patients at high risk for cognitive impairment. METHODS We aimed to associate the levels of Angiopoietin-2 (Ang-2), asymmetric dimethylarginine (ADMA), and a selection of eight circulating angiogenic miRNAs with SVD and cognitive impairment in older patients reaching ESRD that did not initiate renal replacement therapy yet (n = 129; mean age 75.3 years; mean eGFR 16.4 mL/min). We assessed brain MRI changes of SVD (white matter hyperintensity volume, microbleeds and presence of lacunes) and measures of cognition in domains of memory, psychomotor speed and executive function, comprised in a neuropsychological test battery. RESULTS Older patients reaching ESRD showed an unfavorable angiogenic profile, as indicated by aberrant levels of Ang-2 and five angiogenic miRNAs (miR-27a, miR-126, miR-132, miR-223, miR-326), compared to healthy persons and patients with diabetic nephropathy. Moreover, Ang-2 associated with SVD and with the domains of psychomotor speed and executive function, while miR-223 and miR-29a associated with memory function. CONCLUSIONS Taken together, these novel angiogenic markers might serve to identify older patients with ESRD at risk of cognitive decline, as well as give insight into the underlying (vascular) pathophysiology.
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Affiliation(s)
- Roel Bijkerk
- Department of Internal Medicine (Nephrology).,Einthoven Laboratory for Vascular and Regenerative Medicine
| | - Marije H Kallenberg
- Department of Internal Medicine (Nephrology).,Department of Internal Medicine (Gerontology and Geriatrics)
| | - Laurien E Zijlstra
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Bernard M van den Berg
- Department of Internal Medicine (Nephrology).,Einthoven Laboratory for Vascular and Regenerative Medicine
| | - Jeroen de Bresser
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Esther E Bron
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Hakim Achterberg
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Mark A van Buchem
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Willem Jan W Bos
- Department of Internal Medicine (Nephrology).,Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Ton J Rabelink
- Department of Internal Medicine (Nephrology).,Einthoven Laboratory for Vascular and Regenerative Medicine
| | - Anton Jan van Zonneveld
- Department of Internal Medicine (Nephrology).,Einthoven Laboratory for Vascular and Regenerative Medicine
| | - Marjolijn van Buren
- Department of Internal Medicine (Nephrology).,Department of Nephrology, HAGA Hospital, The Hague, The Netherlands
| | - Simon Mooijaart
- Department of Internal Medicine (Gerontology and Geriatrics).,Institute of Evidence-Based Medicine in Old Age, Leiden, The Netherlands
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Schjerlund M, Agnholt H, Gregersen LR, Heilesen T, Pedersen MK. Cognitive impairment in patients with chronic kidney disease-Next of kin's experiences. J Ren Care 2020; 47:87-95. [PMID: 33030815 DOI: 10.1111/jorc.12352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 08/19/2020] [Accepted: 08/26/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chronic kidney disease (CKD) has been associated with a progressive decline in cognitive functions. This may lead to significant consequences for the person with CKD physically, psychologically and socially and may affect the everyday lives of the family. OBJECTIVES To explore the everyday life experiences of next of kin of persons with CKD and cognitive impairment (CI). DESIGN A qualitative design with semi-structured individual interviews with next of kin of persons with CKD and CI to gather in-depth information about the everyday life experiences of the next of kin. Interviews were recorded, transcribed verbatim and analysed inductively based on qualitative thematic analysis. FINDINGS Based on the analysis, four themes were constructed: CI evolves gradually and is multifaceted; balancing everyday life challenges; finding ways to deal with their situation and knowledge enables understanding. CONCLUSION Next of kin took responsibility and developed strategies for making everyday life function for the person with CKD and CI, which required considerable structure and a number of actions. They needed information about the CI and developed strategies for how to protect the person with CKD from being exposed. To provide themselves a personal space, next of kin turned to family, friends and people in comparable situations. To identify and address unmet care needs, healthcare professionals must proactively demonstrate an increased focus on CI and focus on the potential care needs of the person with CKD and their next of kin.
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Affiliation(s)
- Maiken Schjerlund
- Clinic for Internal Medicine and Acute, Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
| | - Hanne Agnholt
- Clinic for Internal Medicine and Acute, Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark.,Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark
| | - Laerke Rohr Gregersen
- Clinic for Internal Medicine and Acute, Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
| | - Tina Heilesen
- Clinic for Internal Medicine and Acute, Department of Nephrology, Aalborg University Hospital, Aalborg, Denmark
| | - Mona K Pedersen
- Clinical Nursing Research Unit, Aalborg University Hospital, Aalborg, Denmark.,Centre for Clinical Research, North Denmark Regional Hospital, Hjoerring, Denmark
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