Optimal Hemodialysis Vascular Access in the Elderly Patient
Kidney Clinical Research Unit, Division of Nephrology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada Division of Nephrology, Department of Medicine, Toronto General Hospital, and the University of Toronto, Toronto, Ontario, Canada Division of Nephrology,W.G. (Bill) Hefner Veterans Affairs Medical Center, Salisbury, North Carolina Department of Nephrology and Department of Medicine, Monash Medical Centre & Monash University, Melbourne, Victoria, Australia Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas Division of Nephrology and Hypertension, University of Cincinnati, Cincinnati, Ohio.Seminars in Dialysis (Impact Factor: 1.75). 11/2012; 25(6):640-648. DOI: 10.1111/sdi.12037
The optimal vascular access for elderly patients remains a challenge due to the difficulty balancing the benefits and risks in a population with increased comorbidity and decreased survival. Age is commonly associated with failure to mature in fistula and decreased rates of primary and secondary patency in both fistula and grafts. In the elderly, at 1 and 2 years, primary patency rates range from 43% to 74% and from 29% to 67%, respectively. Secondary patency rates at 1 and 2 years range from 56% to 82% and 44% to 67%, respectively. Cumulative fistula survival is no better than grafts survival when primary failures are included. Several observational studies consistently demonstrate a lower adjusted mortality among those using a fistula compared with a catheter; however, catheter use in the elderly is increasing in most countries with the exception of Japan. Both guidelines and quality initiatives do not acknowledge the trade-offs involved in managing the elderly patients with multiple chronic conditions and limited life expectancy or the value that patients place on achieving these outcomes. The framework for choice of vascular access presented in this article considers: (1) likelihood of disease progression before death, (2) patient life expectancy, (3) risks and benefits by vascular access type, and (4) patient preference. Future studies evaluating the timing and type of vascular access with careful assessments of complications, functionality, cost benefit, and patients' preference will provide relevant information to individualize and optimize care to improve morbidity, mortality, and quality of life in the elderly patient.
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- "Frailty can also lead to a greater tendency for the formation of bruises on the skin, as a consequence of obtaining vascular access. In addition, there is a greater likelihood of older people taking antiplatelet or anticoagulant drugs, which can potentially increase the risk of bleeding complications (Moist et al., 2012), particularly an issue when used concurrently with certain other drugs, such as selective serotonin re-uptake inhibitors (SSRIs) (Schalekamp et al., 2008). Considering medication as part of patient-centred care, the optimised intervention needs to be an age-appropriate approach, considering and acceding to the needs of the older patient. "
ABSTRACT: The number of older people globally is increasing, contributing to a growing burden of morbidity and mortality. With this shift in population demographic, comes a new challenge in terms of appropriate healthcare for the over 65 years age group. As medication is the principal therapeutic intervention, it is essential that it be fully optimised, to meet the needs of this heterogeneous population. The most common routes of drug administration are oral and injectable, which may display some limitations for older people, in cases of dysphagia or frailty for example. This review considers alternative methods of drug delivery to the norm, specifically discussing the nasal, pulmonary and transdermal routes, as well as novel orally disintegrating tablets. The changing physiology as ageing occurs must be considered in the development of novel drug delivery devices. This review considers the various aspects of ageing that will influence future drug formulation design and development.
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ABSTRACT: Each year a large number of older individuals with advanced renal disease are started on chronic dialysis therapy. Life expectancy is estimated at between 2 and 4 years depending on age, comorbidity, and intensity of medical care required in the weeks around the dialysis start time. Survivors remain at high risk of ongoing morbidity. Regarding quality of life, many older patients express regret over having opted for chronic dialysis therapy and subsequently choose to withdraw from treatment, whereas many others maintain a quality of life similar to that of age-matched peers. Early assessment and ongoing comprehensive geriatric assessment is recommended.
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