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Many older patients with end-stage kidney disease lost the ability to function independently after starting dialysis, and the burden on their caregivers increased, researchers reported.

In 187 patients ages 65 and older initiating dialysis and followed for 6 months, 40% had declines in functional status, 8% died, and 34% remained stable. Only 18% improved, said Namiko Goto, MD, of the University Medical Center Utrecht in The Netherlands, and colleagues.

The functional declines were driven mostly by losses in instrumental activities of daily living, such as shopping, housecleaning, and preparing meals (a 37% decline vs 17% improvement).

According to the study online in , for basic activities of daily living such as bathing, dressing, and feeding oneself, most study participants (66%) remained stable. Among caregivers, those reporting a high level of burden increased from 23% at baseline to 38% at 6 months.

Increasing numbers of older adults are undergoing dialysis for kidney failure, and "unfortunately, little is known about the functional trajectory after initiating dialysis in the elderly patient with end-stage kidney disease," the researchers noted.

They explained that previous studies were done in small, single-center cohorts or nursing home populations, not in the general population of older patients on dialysis. "To our best knowledge, this is one of the first studies that prospectively assessed functional course after initiating dialysis in community-dwelling elderly with end-stage kidney disease," Goto, et al. said.

"It is important to understand what impact the initiation of dialysis has on the course of functional status. Moreover, it is important to try to predict in which patients functional status will improve after initiating dialysis ... and in which it will decline," the team continued. "This can inform patients about prognosis and aid [shared] decision-making regarding dialysis. Furthermore, knowledge about functional change may guide interventions to prevent functional decline or initiate improvement in high-risk patients, such as rehabilitation programs or physical training."

Study Details

The team analyzed data on 187 older adults (mean age 75) enrolled in the Older Patients Starting Dialysis (GOLD) study. One-third of participants were women. All underwent a geriatric assessment and frailty screening at baseline. Functional status, including basic and instrumental activities of daily living, was assessed by validated questionnaires at baseline and phone interviews at 6 months. A functional decline was defined as loss of one or more domains in functional status, and improvement was defined as a gain of one or more domains.

Additionally, the burden on caregivers was assessed via questionnaires at baseline and at 6 months. "As caregiver burden is associated with a decreased quality of life, more symptoms of depression could also lead to negative outcomes for patients, it is important to reduce and prevent caregiver burden," the researchers stated.

"Therefore, physicians should periodically ask caregivers about caregiver burden to address factors that may cause distress (e.g. physical burden, psychosocial burden, behavioral problems). Additional support, such as extended homecare, social work, but also education, can be used to decrease and prevent caregiver burden," the team added.

In a multivariate analysis, age was significantly associated with increased risk for functional decline (OR 1.05, 95% CI 1.00-1.10 per year older at baseline), as was a high score on the Groningen Frailty Indicator (OR 1.97, 95% CI 1.05-3.68 compared with a low score), the researchers reported.

In an , one patient described the dialysis experience this way: "Despite adhering to the treatment schedule and diet, the physical limitations became overpowering and I could not summon up the energy to function ... I never did regain my muscle mass, and rather than improve on dialysis, I had neither the emotional nor physical energy to explore transplantation."

Study limitations, Goto and colleagues said, included that it is likely that healthier patients elected to take part in the study while less healthy patients declined, reducing the generalizability of the findings. In addition, due to the low rate of events, the multivariable models were relatively underpowered and therefore potential associations could be missed.

"Further research should focus on improving the identification of patients at risk for functional decline and interventions that could maintain functional status," Goto and co-authors concluded. "Better identification of the patient at risk for functional decline could lead to better decision-making, and therefore less suffering and less healthcare costs. Moreover, it could lead to preventive strategies with regard to functional decline."