Dialysis takes a toll
NEW YORK — 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 his life? This could be a personal decision, but it helps to understand how the therapy can affect patients and caregivers.
A patient receiving haemodialysis, by far the most common form of this therapy, sits at a clinic in a chair for three to four hours as his 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 United States-based 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 per cent had higher rates of disability three months after the start of the treatment. Within a year, elevated disability rates affected 87 per cent.
“The initiation of dialysis is associated with a substantial and sustained decline in functional status,” the researchers concluded.
This is not just a phenomenon in nursing homes. Another report published in 2009 found that nearly one-third of 97 patients aged 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 and 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 aged 75 and older who started dialysis at Mayo Clinic. A notable finding: Only 37 per cent 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 that this may improve outcomes, said Dr Ann O’Hare, a nephrologist and Associate Professor of Medicine at the University of Washington. However, research data does not support this practice, and it may contribute to difficulties for patients.
Older patients on dialysis often experience medical complications related to treatment (blood clots and infections), are hospitalised more often than those who do not pursue this therapy and die more frequently in the hospital than at home. About half report being in pain, and 20 per cent have symptoms of depression; 25 per cent to 34 per cent of those aged 75 and older eventually choose to discontinue treatment.