Dialysis is difficult for people of any age, but especially for frail older adults with multiple chronic conditions such as diabetes, heart disease and dementia — the patients least likely to have their lives extended significantly by this treatment.
Is dialysis worth its drawbacks if an elderly patient is increasingly ill and near the end of life? That's a personal decision, but it helps to understand how the therapy can affect patients and caregivers.
A patient receiving hemodialysis, by far the most common form of this therapy, sits at a clinic in a chair for three to four hours as her blood passes through a machine that eliminates waste products. Treatment is usually needed three times a week, and it can be exhausting and debilitating.
As seniors on dialysis endure extended periods of inactivity, "they experience a slow, steady decline of their mobility and vitality," said Dr. Bjorg Thorsteinsdottir, an internist at the Mayo Clinic who studies dialysis outcomes in older adults.
Several studies have documented the magnitude of this decline.
In 2009, researchers at Stanford University and the University of California, San Francisco, studied more than 3,000 elderly nursing home residents who were undergoing dialysis and found that 61 percent had higher rates of disability three months after the start of the treatment. Within a year, elevated disability rates affected 87 percent. "The initiation of dialysis is associated with a substantial and sustained decline in functional status," researchers concluded.
This isn't just a phenomenon in nursing homes. Another report published in 2009 found that nearly one-third of 97 patients age 80 and older who were living at home, mostly independently, experienced significant declines in their ability to perform daily activities (using the toilet, bathing, dressing, eating, moving around) within six months of starting dialysis and had to rely on a caregiver or transfer to a nursing home.
Dr. Thorsteinsdottir recently presented results from a study of 379 patients age 75 and older who started dialysis at the Mayo Clinic. A notable finding: Only 37 percent of patients who had lived independently were able to return home after beginning dialysis in the hospital. Others died or were discharged to nursing facilities.
The results are of concern because many doctors are initiating dialysis earlier in the course of kidney disease in the belief this may improve outcomes, said Dr. Ann O'Hare, a nephrologist and associate professor of medicine at the University of Washington. But research data don't support this practice, and it may contribute to difficulties for patients.
Older adults on dialysis often experience medical complications related to treatment (blood clots and infections), are hospitalized more often than those who don't pursue this therapy, and die more frequently in the hospital than at home. About half report being in pain, and 20 percent have symptoms of depression; 25 percent to 34 percent of those age 75 and older eventually choose to discontinue treatment.
Part of the problem is that doctors frequently don't discuss drawbacks with older patients or their caregivers. "Typically we've been paternalistic, and we've tended to make decisions based on our own sense of when a patient needs dialysis," Dr. O'Hare said. "What we've not been very good about is involving patients or families in that decision."
Of course, the potential for dialysis to extend life is the strongest argument in its favor. While the scientific evidence isn't definitive, 80- and 90-year-olds on dialysis may live two to 20 months longer, on average, than they would without it.
Some people do well even when the cards appear stacked against them. Mitch Nimon's 82-year-old father, Melvin Nimon, landed in the hospital twice this year — first with a life-threatening esophageal bleed and then with dehydration. A survivor of gallbladder cancer with short-term memory problems (doctors suspect dementia), a history of diabetes and alarmingly low kidney function, the elder Mr. Nimon began dialysis after his second hospitalization.
"It seemed to me the more seasoned specialists just thought it was a waste of time," said Mitch Nimon, 52, who cares for his father at home in Woodinville, Wash. But after agonizing over the decision, the family elected to give hemodialysis a try.
Doctors "were wrong. It's made a huge difference," said Mr. Nimon, who said his father had regained considerable good health. Mr. Nimon now wants to shift his father to peritoneal dialysis, which can be administered at home.
What is the best way to inform older adults and their caregivers about the likely outcome of dialysis? Researchers at Baystate Medical Center in Massachusetts and the University of New Mexico recently won a $2 million grant from the government to study this question over the next three years.
Researchers will select older patients on dialysis at the highest risk of dying over the next six months, explain their prognosis and examine whether this influences their choice to continue dialysis, complete advance directives or seek hospice services.
"It's a first step to figuring out how we should communicate prognosis," said Dr. Mark Unruh, chief of renal division at the University of New Mexico and a participant in the project.
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