Article

Geriatric comorbidities, such as falls, confer an independent mortality risk to elderly dialysis patients

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Abstract

As the number of patients aged >/=65 years starting haemodialysis (HD) continues to increase, more patients are at risk of falls, functional decline and cognitive impairment. In an earlier prospective cohort study, we showed that 44% of elderly HD patients had more than one fall within a 1-year period. The objective of this study was to assess whether falls remained predictive of increased mortality risk even after controlling for age, comorbidity, dialysis vintage and laboratory variables. Using a prospective, cohort study design, patients aged >/=65 years and on chronic HD during the period April 2002-2003 were recruited. Patients were followed biweekly, and falls occurring within the first year were recorded. Outcome data were collected until death, study end (30 December 2006), transplantation or transfer to another dialysis centre. A total of 162 patients were followed for a median of 32.7 months (quartiles 14-57). In a univariate Cox model with a time-dependent variable for falls status, survival was worse amongst fallers compared to non-fallers (HR 2.13, 95% CI 1.32-3.45; P = 0.002). After adjustment for age, dialysis vintage, comorbidity and laboratory variables, falls were a significant predictor of mortality (HR 1.78, 95% CI 1.07-2.98, P = 0.03). Exclusion of falls associated with concurrent illnesses did not alter the results (HR 1.63, CI 1.02-2.28 P = 0.05). We conclude that the occurrence of more than one accidental fall in a community-dwelling HD patient aged >/=65 years is associated with an independent increased risk of death. As fall interventions are effective, screening HD patients for falls may be a simple measure of clinical importance.

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... Only two studies assessed the association between falls and mortality in elderly haemodialysis patients [13,33]. ...
... Other age-related comorbidities, such as falls, consult an independent and significant mortality risk for geriatric dialysis population. Approximately 40% of elderly dialysis patients encounter one or more unexpected falls within one-year phase [13]. Multiple mediations have been performed to decrease fall rates and/or prevent damage associated with falls. ...
... Multiple mediations have been performed to decrease fall rates and/or prevent damage associated with falls. These consist of multivariate evaluation and intervention, exercise moderating and the use of hip protectors in specific populations [13]. We also found that older age and more combined conditions (such as diabetes mellitus or hypertension) were correlated with higher mortality, which is well known in the general population. ...
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Background: Older haemodialysis patients accompany a high burden of functional impairment, limited life expectancy, and healthcare utilization. This meta-analysis aimed to evaluate how various risk factors influenced the prognosis of haemodialysis patients in late life, which might contribute to decision making by patients and care providers. Methods: PubMed, Embase, and Cochrane Central were searched systematically for studies evaluating the risk factors for mortality in elderly haemodialysis patients. Twenty-eight studies were included in the present systematic review. The factors included age, cardiovascular disease, diabetes mellitus, type of vascular access, dialysis initiation time, nutritional status and geriatric impairments. Geriatric impairments included frailty, cognitive or functional impairment and falls. Relative risks with 95% confidence intervals were derived. Results: Functional impairment (OR = 1.45, 95% CI: 1.20-1.75), cognitive impairment (OR = 1.46, 95% CI: 1.32-1.62) and falls (OR = 1.14, 95% CI: 1.06-1.23) were significantly and independently associated with increased mortality in elderly haemodialysis patients. Low body mass index conferred a mortality risk (OR = 1.43, 95% CI: 1.31-1.56) paralleling that of frailty as a marker of early death. The results also confirmed that the older (OR = 1.43, 95% CI: 1.22-1.68) and sicker (in terms of Charlson comorbidity index) (OR = 1.41, 95% CI: 1.35-1.50) elderly haemodialysis patients were, the more likely they were to die. In addition, increased mortality was associated with early-start dialysis (OR = 1.18, 95% CI: 1.01-1.37) and with the use of a central venous catheter (OR = 1.53, 95% CI: 1.44-1.62). Conclusions: Multiple factors influence the risk of mortality in elderly patients undergoing haemodialysis. Geriatric impairment is related to poor outcome. Functional/cognitive impairment and falls in elderly dialysis patients are strongly and independently associated with mortality.
... In the geriatric population and in patients awaiting renal transplant surgery haemodialysis has traditionally been considered the most viable option. 1 Placement of a radiocephalic arteriovenous fistula (RCAVF) is the procedure of choice for patients with ESRD receiving maintenance haemodialysis because of its reliable patency, low complication rate and preservation of alternate future access sites. However, this procedure is not always easy to perform because of the poor quality of distal cephalic veins, multiple prior venepunctures and cannulations. ...
... Larger vein diameter and high blood flow through the fistula are the two important predictors of successful RCAVF function. 1,3 Anaesthetic modalities used for RCAVF creation such as monitored anaesthesia care, regional blocks and general anaesthesia may affect the characteristics of blood flow across the fistula. 1 RCAVF is the preferred route for haemodialysis but this procedure may not be successful due to intraoperative spasm of the radial artery because of enhanced sympathetic activity. 2,4 Regional anaesthetic techniques have been used to improve the success of vascular access procedures because of sympatholytic effects. ...
... Anaesthetic techniques used for RCAVF creation like monitored anaesthesia care, regional blocks and general anaesthesia may affect the characteristics of blood flow across the fistula and hence influence fistula failure. 1 Malinzak and colleagues suggested that use of regional blocks may improve the success of vascular access procedures by producing significant vasodilatation, greater fistula blood flow, sympatholytic effects and decreased maturation time while minimally altering blood pressure and heart rate. 11 A minimum preoperative vessel diameter of 2 mm was first suggested by Silva and colleagues who reported good AVF outcomes (8% early failure, 83% functional primary patency at 1 year). ...
Article
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Background: Surgical construction of an arteriovenous fistula is preferred for end-stage renal failure patients requiring long-term haemodialysis. Methods: Patients were randomised into two groups: brachial plexus group (n = 30) or local infiltration group (n = 30). In all patients, a radiocephalic arteriovenous fistula was created by an experienced surgeon using a standard surgical technique. In both groups 20 ml of 0.375% ropivacaine was used. Doppler assessment of vessels was performed at fixed time intervals. Results: Primary patency rate was 100% in the brachial plexus block group whereas there was 10% fistula failure rate in the local infiltration group (p-value = 0.237). Diameter of the vessels, peak systolic velocity, mean diastolic velocity, and blood flow at 30 minutes, 48 hours, 2 weeks, and 6 weeks after the fistula creation was significantly greater than the preoperative diameter in all patients (p-value < 0.05). Intergroup comparison revealed that vascular parameters were significantly better in the brachial plexus analgesia group versus local infiltration group at all observation points up to and including six weeks post fistula creation (p-value < 0.05). Conclusion: Brachial plexus anaesthesia significantly dilates the vessel diameter and increases blood flow whereas local infiltration has a negligible effect on vessel diameter and blood flow. Keywords: arteriovenous fistula, end-stage renal disease, ultrasound guided supraclavicular block
... Hemodiyaliz hastalarında mortaliteyi ve yaşam kalitesini etkileyen birçok komorbid etken vardır (2,3). Bu etkenler arasında anksiyete, depresyon, yorgunluk ve düşme yer almaktadır (4)(5)(6). Düşmeler de HD hastalarında önemli düzeyde negatif sonuçları olan bir durumdur (5,6). Düşmelere odaklanan makale sayısının son yıllarda artış göstermesine karşın, HD hastalarında düşme ve risk faktörlerini inceleyen az sayıda çalışmaya ulaşılabilmiştir (6)(7)(8). ...
... Bu etkenler arasında anksiyete, depresyon, yorgunluk ve düşme yer almaktadır (4)(5)(6). Düşmeler de HD hastalarında önemli düzeyde negatif sonuçları olan bir durumdur (5,6). Düşmelere odaklanan makale sayısının son yıllarda artış göstermesine karşın, HD hastalarında düşme ve risk faktörlerini inceleyen az sayıda çalışmaya ulaşılabilmiştir (6)(7)(8). ...
... More than one-third of communityliving adults older than 65 years fall each year and about 10% of falls result in fracture, serious soft tissue injury, or traumatic brain damage, thus falls and fall-related injuries are major contributors to functional decline and health care utilization [1]. High rates of gait abnormalities, falls and fall-related injuries in patients with chronic kidney disease (CKD) have been documented [2][3][4][5][6][7][8][9][10][11]. Moreover, patients with CKD usually represent an aging population. ...
... Given the association with accelerated aging and high rate of sarcopenia, dynapenia and immobility, CKD was proposed as an ideal clinical disorder to apply physical performance testings [14]. In addition to low quality of life, patients with CKD and low physical performance status are more likely to die or develop endstage kidney disease [6,14,15]. Moreover, exercise programs increased the quality of life and performance status of patients with stage 3-4 CKD and patients on dialysis [8,[16][17][18][19]. ...
Article
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PurposePatients with chronic kidney disease (CKD) usually represent an aging population, and both older age and CKD are associated with a higher risk of falling. Studies on risk factors among subjects with CKD are lacking.Methods Records of outpatients from one geriatric clinic in Turkey were retrospectively reviewed. A result of ≥ 13.5 s on the timed up and go (TUG) test was accepted as a high risk of falls. Independent predictors of an increased risk of falls among subjects with CKD (estimated glomerular filtration rate of < 60 mL/min/1.73 m2) were identified using logistic regression models.ResultsPatients with CKD (n = 205), represented the 20.2% of the entire cohort and was identified as an independent predictor of increased fall risk (OR 2.59). Within the CKD cohort, serum folic acid levels and frailty were independent predictors of an increased risk of falls. The CKD/fall risk group was older, had a lower median years of education, lower vitamin D levels, and lower serum folic acid levels than the CKD/non-fall risk group. In addition to higher serum creatinine and potassium levels, the only significant difference between patients with CKD/fall risk and a matched non-CKD/fall risk was a lower median folic acid level in the former group.Conclusions Frailty and low folic acid levels are independently associated with an increased risk of falls among elderly outpatients with CKD. Prevention of frailty may reduce the risk of falls in these subjects. Possible benefit of folic acid supplementation requires further studies.
... Therefore, clinicians should identify the factors that carry risks of mortality or of increased caregiving constraints and medical costs after older patients have entered dialysis treatment. Studies have identified several mortality risk factors in older adults undergoing dialysis [16][17][18][19]. Tamura et al. showed that most institutionalized older adults died after one year and suffered deteriorating quality of life after initiation of dialysis [20]. ...
... Our data also could help family members and aged patients to decide whether receiving dialysis or not, especially for those more aged and more comorbidities. Li et al. revealed falls as an independent risk factor for mortality among older adults [16]. However, one identifiable risk factor alone might not suffice for making decisions regarding dialysis. ...
Article
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Background: Prognosis of the aged population requiring maintenance dialysis has been reportedly poor. We aimed to develop prediction models for one-year cost and one-year mortality in aged individuals requiring dialysis to assist decision-making for deciding whether aged people should receive dialysis or not. Methods: We used data from the National Health Insurance Research Database (NHIRD). We identified patients first enrolled in the NHIRD from 2000-2011 for end-stage renal disease (ESRD) who underwent regular dialysis. A total of 48,153 Patients with ESRD aged ≥65 years with complete age and sex information were included in the ESRD cohort. The total medical cost per patient (measured in US dollars) within one year after ESRD diagnosis was our study's main outcome variable. We were also concerned with mortality as another outcome. In this study, we compared the performance of the random forest prediction model and of the artificial neural network prediction model for predicting patient cost and mortality. Results: In the cost regression model, the random forest model outperforms the artificial neural network according to the mean squared error and mean absolute error. In the mortality classification model, the receiver operating characteristic (ROC) curves of both models were significantly better than the null hypothesis area of 0.5, and random forest model outperformed the artificial neural network. Random forest model outperforms the artificial neural network models achieved similar performance in the test set across all data. Conclusions: Applying artificial intelligence modeling could help to provide reliable information about one-year outcomes following dialysis in the aged and super-aged populations; those with cancer, alcohol-related disease, stroke, chronic obstructive pulmonary disease (COPD), previous hip fracture, osteoporosis, dementia, and previous respiratory failure had higher medical costs and a high mortality rate.
... -Functional status for basic activities of daily living was assessed using the Barthel index. [18][19][20] This classifies patients as independent (score 91-100), minor dependency (61-90), moderate dependency (41-60), severe dependency (21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40) or total dependency (20 points or below). -Cognitive assessment was performed using the Pfeiffer test. ...
... The geriatric assessment [30][31][32][33] provides an overall approach to older people through clinical assessment (with identification of chronic diseases and nutritional aspects), functional assessment, cognitive assessment, psychosocial assessment and frailty, and is becoming increasingly important in patients with CKD. 18 Assessment and treatment require a multidisciplinary approach in patients with CKD, with strategies that identify factors for worse prognosis which can help in decision making. ...
Article
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Introduction Conservative Management (CM) has become a therapeutic option in Advanced Chronic Kidney Disease in the elderly. However, there is a lack of evidence about prognosis of these patients in terms of survival and health related quality of life (HRQoL). Objective Establish predictive variables associated with mortality and analyse HRQoL in CM patients. Patients and methods Prospective cohort study. An assessment of renal function parameters and a comprehensive geriatric assessment were made, including: analysis of comorbidity, functional, cognitive, fragility, nutritional, social and HRQoL status. Results 82 patients with a mean age of 84 years and significant pluripathology were studied: 56% had history of vascular event and Charlson >8. The mortality rate was 23/1000 patients per month, with a homogeneous mortality rate after 6 months. Survival differed significantly depending on whether they presented with a previous vascular event (36.7 vs. 14.8; p = 0.028), Charlson score ≥ 10 (42 vs. 17; p = 0.002), functional status (48.4 vs. 19; p = 0.002) and fragility (27 vs. 10; p = 0.05). Mortality predictors included eGFR and proteinuria, the presence of previous vascular events, Charlson comorbidity score, malnutrition-inflammation parameters (albumin and MNA score), degree of dependency, physical HRQoL and increase of PTH level. The presence of previous vascular event, comorbidity, decreased albumin and elevated PTH were independent predictors of mortality. HRQoL remained stable over time and no significant worsening occurred during treatment. Conclusions Having knowledge of the factors associated with mortality and HRQoL assessment can be a useful tool to helping decision making during CM. Previous vascular events, comorbidity, decreased albumin and increased PTH were independent predictors of mortality.
... [4][5][6][7][8][9] The incidence of falls and fractures increases in HD patients with abnormal bone metabolism because of declining physical function. [10][11][12] Moreover, the incidence of hip fracture is five times higher in HD patients than in community-dwelling elderly patients. 13) Therefore, HD patients with hip fractures are often eligible for physical therapy. ...
Article
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Objectives: The aim of this study was to investigate the influences of hemodialysis (HD) on activities of daily living (ADL) in patients with hip fracture. Methods: This study included 28 patients (14 HD and 14 non-HD patients) with acute hip fracture. The effects of variables such as age, sex, surgical procedure, length of hospital stay, serum albumin, C-reactive protein (CRP), number of physical therapy units, and functional independence measure (FIM) were assessed. For each factor, a two-group comparison was conducted between the HD and non-HD groups. Multiple regression analysis was used to examine the factors affecting FIM efficacy (E-FIM). Results: For HD patients, total and motor FIM at discharge, E-FIM, and albumin level were significantly lower than in non-HD patients. Length of hospital stay was significantly longer for HD patients. Multiple regression analysis showed that HD had a negative effect on E-FIM. Conclusions: The results suggest that rehabilitation for HD patients with hip fractures require intervention that not only provides standard rehabilitation but also addresses aspects of renal rehabilitation.
... Older end-stage renal disease (ESRD) patients receiving hemodialysis (HD) are often frail, 1 susceptible to falls, 2,3 are mobility-impaired, and have more functional disability relative to the age-matched general population. 4,5 These factors associate with an increased risk of mortality [6][7][8] and impede achievement of inpatient rehabilitation goals. 9,10 Dialysis patients residing in skilled nursing facilities (SNFs) are predominantly older and also have considerable comorbidity, frailty, and functional dependence. ...
Article
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Introduction For end‐stage renal disease (ESRD) patients residing in skilled nursing facilities (SNFs), the logistics and physical exhaustion of life‐saving hemodialysis therapy often conflict with rehabilitation goals. Integration of dialysis care with rehabilitation programs in a scalable and cost‐efficient manner has been a significant challenge. SNF‐resident ESRD patients receiving onsite, more frequent hemodialysis (MFD) have reported rapid post‐dialysis recovery. We examined whether such patients have improved Physical Therapy (PT) participation. Methods We conducted a retrospective electronic medical records review of SNF‐resident PT participation rates within a multistate provider of SNF rehabilitation care from January 1, 2022 to June 1, 2022. We compared three groups: ESRD patients receiving onsite MFD (Onsite‐MFD), ESRD patients receiving offsite, conventional 3×/week dialysis (Offsite‐Conventional‐HD), and the general non‐ESRD SNF rehabilitation population (Non‐ESRD). We evaluated physical therapy participation rates based on a predefined metric of missed or shortened (<15 min) therapy days. Baseline demographics and functional status were assessed. Findings Ninety‐two Onsite‐MFD had 2084 PT sessions scheduled, 12,916 Non‐ESRD had 225,496 PT sessions scheduled, and 562 Offsite‐Conventional‐HD had 9082 PT sessions scheduled. In mixed model logistic regression, Onsite‐MFD achieved higher PT participation rates than Offsite‐Conventional‐HD (odds ratio: 1.8, CI: 1.1–3.0; p < 0.03), and Onsite‐MFD achieved equivalent PT participation rates to Non‐ESRD (odds ratio: 1.2, CI: 0.3–1.9; p < 0.46). Baseline mean ± SD Charlson Comorbidity score was significantly higher in Onsite‐MFD (4.9 ± 2.0) and Offsite‐Conventional‐HD (4.9 ± 1.8) versus Non‐ESRD (2.6 ± 2.0; p < 0.001). Baseline mean self‐care and mobility scores were significantly lower in Onsite‐MFD versus Non‐ESRD or Offsite‐Conventional‐HD. Discussion SNF‐resident ESRD patients receiving MFD colocated with rehabilitation had higher PT participation rates than those conventionally dialyzed offsite and equivalent PT participation rates to the non‐ESRD SNF‐rehabilitation general population, despite being sicker, less independent, and less mobile. We report a scalable program integrating dialysis and rehabilitation care as a potential solution for ESRD patients recovering from acute hospitalization.
... One study has shown that one accidental fall in a community of HD patients aged ≥ 65 years was associated with an increased independent risk of death [18]. Another study has suggested that the prevention of each serious fall would have resulted in cost savings between $25,158 and $36,781 [19]. ...
Article
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Background Aging and an increased fall risk have been demonstrated in hemodialysis patients at home and in a facility. However, studies investigating the cause of falls to prevent fractures in dialysis rooms are scarce. This study aimed to explore the related factors for accidental falls statistically in dialysis facilities for future fall prevention. Methods This study included 629 hemodialysis patients with end-stage renal disease. The patients were divided into two groups: the fall and non-fall groups. The main outcome was the presence or absence of falls in the dialysis room. Univariate and multivariate logistic analyses were performed; multivariate analysis was conducted using covariates significantly correlated in the univariate analysis. Results A total of 133 patients experienced falling accidents during the study period. The multivariate analysis indicated that the use of walking aid (p < 0.001), orthopedic diseases (p < 0.05), cerebrovascular disease, and age were significantly correlated with falls. Conclusions In the dialysis clinic, patients who use walking aids and have complicated orthopedic or cerebrovascular conditions are at a high risk of falling in the dialysis room. Therefore, establishing a safe environment may help prevent falls, not only for these patients but also among other patients with similar conditions.
... Long-term dialysis in MHD patients decreases physiological reserves, induces loss of nutrients from the body, and confers a higher risk of falls [20]. Falls not only induce direct harm to patients and prolong the hospitalization duration but also affect the mental health of patients, increase medical costs, and reduce the quality of life [21]. This study investigated the occurrence of falls of 303 patients with MHD, analyzed the risk factors related to falls, and obtained the nomogram to evaluate the risk of falls in MHD patients. ...
Article
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This study investigated the prevalence of falls in maintenance hemodialysis (MHD) patients, and established a nomogram model for evaluating the fall risk of MHD patients. This study enrolled 303 MHD patients from the dialysis department of a tertiary hospital in July 2021. The general data of the participants, as well as the scores on the FRAIL scale, Sarcopenia Screening Questionnaire (SARC-F), Short Physical Performance Battery (SPPB) Scale, and of anxiety and depression, and the occurrence of falls were recorded. Using R language, data were assigned to the training set (n = 212) and test set (n = 91), and a logistic regression model was established. The regression model was verified by the receiver operating characteristic (ROC) curve, area under the curve (AUC), and the calibration curve. As a result, the prevalence of falls in MHD patients was 20.46%. Risk factors for falls in the optimal multivariate logistic regression model included hearing impairment, the depression score, and the SPPB score, of which a higher depression score (odds ratio (OR): 1.28, 95% confidence interval (CI): 1.09–1.49, p = 0.002) and SPPB ≤ 6 (ORvsSPPB9-12: 3.69, 95% CI: 1.04–13.14, p = 0.043) conferred independent risk for falls. AUC of the nomogram in the training was 0.773, which in the test group was 0.663. The calibration and standard curves were fitted closely, indicated that the evaluation ability of the model was good. Thus, a higher depression score and SPPB ≤ 6 are independent risk factors for falls in MHD patients, and the nomogram with good accuracy and discrimination that was established in this study has clinical application value.
... In addition, the method used to identify the fall history can be considered a limitation as self-report methods may be influenced by difficulties recalling fall episodes [42]. Falls are known to be multifactorial in nature and other factors that were not included (e.g., polypharmacy [43], comorbidities [44], and physical activity status [45]). ...
Article
Background Nursing home residents are likely to differ from community older adults when their gait parameters are compared, as nursing home residents present more falls Aim The study aim was to identify the main fall occurrence predictors (anthropometrics, functional and gait-related parameters) between older adults living in community and nursing homes during self-selected (SSWS) and fast walking speeds (FWS). Methods A hundred and sixty-five older adults were selected from the community (n= 92) and nursing home (n=73) with and without fall history. They were assessed for fall history, functionality, cognitive status, and several gait parameters in SSWS and FWS conditions. Results Fallers differed from non-fallers in the SSWS, while such differences were not evidenced during the FWS. Cadence and stride width did not differ when living backgrounds were compared. Nursing home residents walked slower than their non-institutionalized peers, regardless of fall history or walking speed. Besides, binary logistic regression analysis showed that living in a nursing home, age, body mass index (BMI), mini-mental state examination (MMSE), and step width were related to falls in the SSWS. On the other hand, living in a nursing home, having a larger BMI and low MMSE scores were fall predictors in the FWS. Conclusion Fall occurrence can be identified by factors related to living in nursing homes, cognitive status, BMI, and gait parameters, at the SSWS. Cognitive status and BMI are related to falls in the FWS for those living in nursing homes.
... Fifteen studies on falls in HD patients were extracted (Table 1). Approximately 30-60% of HD patients experience falls [18][19][20][21][22][23][24][25][26], and of these, 30-57% of patients had multiple falls [18,21,[24][25][26]. The rate of severe falls requiring medical attention was 10.7-19.0% ...
Article
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Falls are a social problem that increase healthcare costs. Hemodialysis (HD) patients need to avoid falling because fractures increase their risk of death. Nutritional problems such as frailty, sarcopenia, undernutrition, protein-energy wasting (PEW), and cachexia may increase the risk of falls and fractures in patients with HD. This review aimed to summarize the impact of frailty, sar-copenia, undernutrition, PEW, and cachexia on falls in HD patients. The reported global incidence of falls in HD patients is 0.85-1.60 falls per patient per year. HD patients fall frequently, but few reports have investigated the relationship between nutrition-related problems and falls. Several studies reported that frailty and undernutrition increase the risk of falls in HD patients. Nutritional therapy may help to prevent falls in HD patients. HD patients' falls are caused by nutritional problems such as iatrogenic and non-iatrogenic factors. Falls increase a person's fear of falling, reducing physical activity, which then causes muscle weakness and further decreased physical activity; this cycle can cause multiple falls. Further research is necessary to clarify the relationships between falls and sarcopenia, cachexia, and PEW. Routine clinical assessments of nutrition-related problems are crucial to prevent falls in HD patients.
... An extension of the FEPOD trial showed better symptom control in patients on asPD compared to those on conservative care with similar renal treatment satisfaction scores 4 . There is, however, no evidence that compared to conservative care, dialysis, either PD or HD improves survival in co-morbid patients or those over 80 years 5,6,7,8 . There are no studies determining how much small solute removal would benefit these patients, but it is likely to be less than patients who are more physically active and have a greater nutritional input. ...
Article
We have developed a supportive two-exchange assisted continuous ambulatory peritoneal dialysis (asCAPD) programme for the older frail person who cannot do autonomous PD and do not want or are considered to be too high risk for haemodialysis (HD). Evaluation of the programme was determined by data collected retrospectively from patient records. Primary outcome was comparison of symptoms at start of dialysis and 3 months following dialysis start. Secondary outcomes were survival and peritonitis rate. Over a 4-year period (2016–2020), 49 patients with mean age 79.6 years (range 47–90) enrolled in the programme with eGFR 7.7 ± 2.6 ml/min (mean ± SD) at dialysis start. Forty-one patients had been on asCAPD for >3 months. There was an improvement in all symptoms at 3 months compared to baseline: anorexia (46% to 15%), fatigue (46% to 15%), shortness of breath (27% to 2%) and oedema (51% to 32%). One-year survival was 55%. Peritonitis rate was 0.52 episodes per patient year. The novel supportive two-exchange asCAPD programme shows potential improvement of symptoms after 3 months and may provide an acceptable dialysis modality for the frail co-morbid person with established kidney failure. More detailed study and evaluation are needed.
... It has been reported that approximately 30% of community-dwelling elderly, aged ≥70 years, experience a yearly fall [14]. In this study, accidental falls occurred in 55.8% of HD patients whose median age was 74.0 years (Fig. 1a), suggesting that the frequency of falls in HD patients was much higher than in the general elderly population, as previously reported [10,15,16]. Frequent falls more than twice a year and fractures associated with falls occurred in 33.3 and 15.7% of patients, respectively. ...
Article
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Background: Patients with chronic kidney disease undergoing hemodialysis (HD) have a high incidence of falls. Impairment of balance function is a risk factor for falls in the general elderly, and no report examining the association between balance dysfunction and fall incidence in HD patients exists. Methods: This prospective cohort study was conducted at a single center. The timed-up-and-go test (TUG) as a dynamic balance function was performed and length of the center of pressure (CoP) as a static balance function was measured before and after the HD session at baseline. Data of the number and detailed information of accidental falls for 1 year were collected. Multiple regression analyses were performed to assess the relationships between the number of falls and balance function. Results: Forty-three patients undergoing HD were enrolled in the study. During 1 year of observation, 24 (55.8%) patients experienced accidental falls. TUG time was longer, and CoP was shorter in the post-HD session than in the pre-HD session. Adjusted multiple regression analyses showed that the number of accidental falls was independently associated with TUG time in the pre-HD session (B 0.267, p < 0.001, R2 0.413) and that in the post-HD session (B 0.257, p < 0.001, R2 0.530), but not with CoP. Conclusions: Dynamic balance was associated with fall incidence in maintenance HD patients. The evaluation and intervention of dynamic balance function might reduce the risk of falls in HD patients. Trial registration: This study was carried out with the approval of the Niigata Rinko Hospital Ethics Committee (approval number 2005-92) (Registered on December 11, 2019) and registered in The University Hospital Medical Information Network (registration number 000040618 ).
... One of the aims in care for sarcopenia remains to limit falls. The increase in risk of fall is well documented in CKD, 44,45 in particular in end-stage renal disease 46,47 and in patients >65 years old. Above age 65, falls are more frequent and often generate complications, especially when GFR is <45 mL/min, with the incidence of falls about 38.3 vs 21.7/ 1000 person-years with GFR>60. ...
Article
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Aging represents a major concern, with a two-fold increase in individuals >65 years old by 2040. Older patients experience multiple declines in condition, with overlapping concerns. Fractures, frailty and falls remain underestimated events in routine practice. They are shared by numerous conditions and diseases, such as osteoporosis, sarcopenia and undernutrition, which mostly feature low evolution and are silent. In this review, we focused on musculoskeletal decline in older individuals who also have chronic kidney disease (CKD), which promotes fractures and falls. We aimed to highlight the need for a global approach for musculoskeletal and kidney aging. Although strategies limiting falls remain controversial, the need for an early diagnosis can limit these declines and allow for specific treatment of bone fragility in addition to non-pharmacological approaches. The emergence of senolytic agents offers new hope for preventing musculoskeletal disorders. This scoping review describes these overlapping silent diseases, provides evidence for their global understanding and management, and sheds light on new therapeutic directions.
... The incidence of falls ranges between 1.2 and 1.6 falls/patient-year, compared to 0.6 to 0.8 falls/patient-year in the general older population [8,9]. Falls are a predictor of mortality in people receiving HD and are also associated with reduced mobility, independence, quality of life, and poorer transplant outcomes [10][11][12][13][14][15]. Falls can also lead to injury, including increased fracture risk due to renal osteodystrophy, as well as hospital admissions, adding to an already high level of healthcare utilisation in this population [12,[16][17][18]. ...
Article
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The prevalence of falls is high in people receiving haemodialysis (HD). This study aimed to explore the experiences of people receiving HD who had fallen in the last six months. A qualitative study, informed by constructivist grounded theory, used semi-structured interviews in combination with falls diaries. Twenty-five adults (mean age of 69 ± 10 years, 13 female, 13 White British) receiving HD with a history of at least one fall in the last six months (median 3, IQR 2–4) participated. Data were organised within three themes: (a) participants’ perceptions of the cause of their fall(s): poor balance, weakness, and dizziness, exacerbated by environmental causes, (b) the consequences of the fall: injuries were disproportionate to the severity of the fall leading to loss of confidence, function and disruptions to HD, (c) reporting and coping with falls: most did not receive any specific care regarding falls. Those who attended falls services reported access barriers. In response, personal coping strategies included avoidance, vigilance, and resignation. These findings indicate that a greater focus on proactively identifying falls, comprehensive assessment, and timely access to appropriate falls prevention programmes is required to improve care and outcomes.
... Elderly ESRD patients have many comorbidities and social, physical, psychological challenges [9]. These challenges like frailty, falls, and functional impairment increase the risk of mortality in CKD patients [10,11]. When choosing the modality of renal replacement therapy life expectancy also becomes an important parameter for clinicians. ...
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Introduction: Elderly patients have increased morbidity and mortality compared to younger patients due to existing comorbid diseases and chronic immunosuppression. Therefore, the option of kidney transplantation for renal replacement therapy in elderly patients is still being controversial. Our aim in this study was to evaluate graft function, graft and patient survival, and associated factors in kidney transplant recipients over 65 years of age, at 11 years of follow-up. Methods: The study included 53 patients aged 65-76 years, out of a total of 1319 patients who underwent live kidney transplantation in the Organ Transplant Center of Acibadem International Hospital between October 2010 and July 2021. Demographic characteristics and creatinine values were recorded. Graft survival rates and patient survival rates at one, three, and five years were analyzed. Results: Fifty-three patients, 14 female, 39 male, aged 65-76 years were included in the study. The follow-up period of the patients was 7-125 months. During the follow-up, 20 patients died. Graft loss occurred in two of 20 patients who died, and 18 patients died with working grafts. Graft loss developed in two of the 33 surviving patients. In the whole group, one-, three-, and five-year patient survival rates were 94%, 81%, and 76%, respectively. Conclusion: These results emphasize that kidney transplantation is a viable treatment option in elderly patients who have been well evaluated before kidney transplantation.
... Changes in sodium chloride levels induce changes in albumin synthesis and catabolism, which influence the inflammatory and nutritional status of patients on MHD. [12,13] Li et al [17] demonstrated that low Salb was associated with functional falls and independently increased the risk of death among elderly adults on HD. Moreover, studies have shown that changes in nutrition affect albumin synthesis, whereas inflammation and hypoalbuminemia increase the rate of fractional albumin catabolism. ...
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Studies have shown that low serum albumin (Salb) levels are associated with a high risk of mortality among patients on maintenance hemodialysis (MHD); however, the impact of Salb variability on short-term cardiovascular mortality remains unclear. Herein, we investigated the association between Salb levels and Salb variability on short-term all-cause and cardiovascular-related mortality in patients on MHD. Eligible patients on MHD at Chongqing General Hospital between June 2017 and June 2020 were recruited in this study. Patients were grouped by Salb levels (normal Salb, ≥3.8 g/dL; low Salb, 3.4–3.8 g/dL; and lower Salb, 2–3.4 g/dL) and Salb variability (decreased, >5% loss; increased, >5% gain; and steady, 5% loss to 5% gain). Associations between Salb levels, Salb variability, and all-cause and cardiovascular-related mortality were analyzed using Cox regression models. A survival analysis was performed using the Kaplan–Meier analysis. We enrolled a total of 181 patients on MHD with an average age of 65 years (interquartile range [IQR], 53–75 years). The mean Salb level was 3.8 ± 0.6 g/dL (IQR 2.9–4.4 g/dL), and the median Salb variability was 2.6% per year (IQR, −4.1 to 6.5). Fifty-two (29%) patients died, including 31 (17%) patients who died due to cardiovascular-related causes. Compared with the other groups, the lower Salb group had higher all-cause mortality (P < .01). Cox regression analyses revealed that lower Salb levels and decreased Salb variability were independently associated with all-cause mortality (hazard ratio [HR] = 1.95, 95% confidence interval [CI] 1.103–3.452; HR = 2.245, 95% CI 1.084–4.650), whereas increased Salb variability was independently associated with cardiovascular-related mortality (HR = 2.919, 95% CI 1.178–7.234; P < .05). Lower Salb levels were an independent predictor of all-cause mortality in patients on MHD. Increased Salb variability was strongly associated with cardiovascular-related mortality in the same population, especially in the short-term and in patients with normal Salb levels. Significantly elevated Salb variability should be evaluated to reduce cardiovascular-related mortality.
... Falls are common in the geriatric population, particularly in those with chronic debilitating conditions such as osteoporosis or neurological limitations (24). In such cases, BPPV is an increased risk factor for falls, and its immediate treatment is therefore crucial. ...
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Introduction: Benign Paroxysmal Positional Vertigo is seen in all age groups; however, its incidence increases with age. In addition to many factors affecting its treatment, aging is also thought to have an effect on treatment. The aim of this study is to investigate the relationship between the number of maneuvers applied in treatment and patient's age, gender and the affected canal. Materials and Method: In total 290 subjects, between 18 to 87 years were included in the study. The positional tests were performed and the appropriate maneuver was performed based on affected canal. Following third day the maneuver positional tests were repeated. If the symptoms and / or nystagmus continued, maneuver was performed again. Results: It was found that older adults require higher number of maneuvers to recover (p<0.05, r= 0.33). In addition, comorbidities such as hypertension and migraine were observed more frequently in older adults compared to the other groups. Conclusion: Changes and comorbidities caused by aging render treatment process far and difficult in the elderly.
... Sarcopenia increases the risks for adverse health outcomes such as falls, physical disability, hospital admission, poor quality of life, and mortality risk [5,6]. In fact, hemodialysis patients have high risks for falls not only because of aging but also because of unstable hemodynamic status or some comorbidities, and falls are associated with increased mortality risk among these patients [7,8]. The EWGSOP recommends that muscle mass should be measured using computed tomography (CT) scans and magnetic resonance imaging (MRI) as the gold standard. ...
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Abstract Background Accidental fall risk is high in patients undergoing maintenance hemodialysis. Falls are associated with fatal injury, comorbidities, and mortality. Risk assessment should be a primary component of fall prevention. This study investigated whether quadriceps muscle thickness measured using ultrasonography can predict fall injury among dialysis patients. Methods Using an observational cohort study design, 180 ambulatory hemodialysis patients were recruited from 2015 to 2016 from four dialysis clinics. The sum of the maximum quadriceps muscle thickness on both sides and the average of the maximum thigh circumference and handgrip strength after hemodialysis were calculated. Patients were stratified according to tertiles of quadriceps muscle thickness. Fall injury was surveyed according to the patient’s self-report during the one-year period. Results Among the 180 hemodialysis patients, 44 (24.4%) had fall injuries during the 12-month follow-up period. When the quadriceps muscle thickness levels were stratified into sex-specific tertiles, patients in the lowest tertile were more likely to have a higher incidence of fall injury than those in the higher two tertiles (0.52 vs. 0.19 and 0.17 fall injuries/person-year). After adjusting for covariates, lower quadriceps muscle thickness was found to be an independent predictor of fall injury (hazard ratio [95% confidence interval], 2.33 [1.22–4.52], P
... It is commonly accepted that the fall is perceived as a disaster that affects the elderly. The epidemiology of equilibrium disorders in Tunisia is unfortunately unknown although this disorder con- Our results show a gender parity (sex ratio = 1) unlike other studies [6][7][8][9] which have found a male predominance ( Table 2). ...
... Older adults with end-stage renal disease (ESRD) are the largest segment of the patient population undergoing hemodialysis (HD) and experience a high prevalence (70%) of physical frailty, which increases their risk for poor health outcomes and cardiovascular mortality [1]. Older HD patients show a particularly reduced physical function profile, which increases their risk for mobility impairment, falls, and cognitive impairment [2][3][4][5]. ...
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Purpose The present study aimed to evaluate the impact of a filmed research-based drama—Fit for Dialysis—and an exercise program on patients’ physical activity and fitness outcomes. Methods Nineteen (10 at the intervention site, 9 at the control site) older patients with a medical diagnosis of hemodialysis-dependent end-stage renal disease were recruited from two acute care hospitals in urban central Canada where they were receiving out-patient hemodialysis care. Participants at the intervention site viewed Fit for Dialysis prior to participating in a 16-week exercise program. Participants at the control site participated only in the 16-week exercise program. Physical activity, measured by total intradialytic exercise time (TIDE), and physical fitness, measured by the Two-Minute Walk Test (2MWT). Secondary measures included: Timed Up and Go (TUG), Grip Strength, Duke Activity Status Index (DASI), Godin Leisure-Time Exerciser Questionnaire (GLTEQ), and pedometer step count. Results TIDE, TUG, and GLTEQ were better at the intervention site compared to the control site at all time points measured. However, the change over time was not different between the sites. The 2MWT improved over time at the intervention site for those who exercised consistently. No significant differences between sites, or over time were found for any of the other measures. Conclusions Further research is needed to determine the effectiveness of this intervention to facilitate the incorporation of exercise into the care and treatment of HD patients.
... Sarcopenia increases the risks for adverse health outcomes such as falls, physical disability, hospital admission, poor quality of life, and mortality risk 5,6 . In fact, hemodialysis patients have high risks for falls not only because of aging but also because of unstable hemodynamic status, or some comorbidities, since falls are associated with increased mortality risk among these patients 7,8 . The EWGSOP recommends that the muscle mass should be measured using computed tomography (CT) scan and magnetic resonance imaging (MRI) as the gold standard. ...
Preprint
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Introduction: Accidental fall risk is high in patients undergoing maintenance hemodialysis. Falls are associated with fatal injury, comorbidities, and mortality. Risk assessment should be conducted as a primary intervention to prevent falls. This study investigated whether quadriceps muscle thickness measured using ultrasonography can prospectively predict fall injury among dialysis patients. Methods: Using an observational cohort study design, 180 ambulatory hemodialysis patients during the period 2015–2016 were recruited in the four dialysis clinics. The sum of the maximum quadriceps muscle thickness on both sides and the average of the maximum thigh circumference and handgrip strength after hemodialysis were calculated. Patients were stratified according to tertiles of quadriceps muscle thickness. Fall injury was surveyed according to the patient’s self-report for the one-year period. Results: Among the 180 hemodialysis patients, 42 (23.3%) had fall injury during the 12-month follow-up period. When the quadriceps muscle thickness levels were stratified into sex-specific tertile, patients in the lowest tertile (men <3.66 cm and women <3.50 cm) were more likely to have higher incidence of fall injury compared with those in the higher two tertiles (0.56 vs. 0.18 and 0.15 fall injuries/person-year). After adjusting for covariates, lower quadriceps muscle thickness was found to be an independent predictor for fall injury (hazard ratio [95% confidence interval], 2.99 [1.46–6.32], P < 0.001). Conversely, no significant differences were found in the thigh circumference and handgrip strength between women with fall injury and those women without fall injury. Conclusions: Quadriceps muscle thickness using ultrasonography can be measured easily at the bedside and is a precise predictor of fall injury in patients undergoing maintenance hemodialysis.
... 57 Injurious falls in the dialysis population are also common 58 and are associated with loss of independence 54 and increased mortality. 59 In addition to injury, falls can also lead to fear of falling, which can subsequently lead to loss of mobility and social isolation. 60 Most risk factors for accidental falls in older persons with ESKD are similar to the general population and include age, a previous fall, diabetes, frailty, mobility impairment, use of anti-depressants, and decrease of systolic blood pressure. ...
Article
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Decision-making in older persons with end-stagebkidney disease (ESKD) regarding dialysis initiation is highly complex. While some older persons improve with dialysis and maintain a good quality of life, others experience less benefit and multiple complications due to a high morbidity burden and (early) mortality. Geriatric impairments are highly prevalent among this population and these impairments may complicate the care of an older person with ESKD. Knowledge of these impairments can potentially help improve care and decision-making regarding dialysis initiation and advance care planning. Therefore, the aim of this review is to give healthcare providers an insight into the existing literature on geriatric impairments in older persons with ESKD. Furthermore, specific areas of concern will be discussed, in combination with some practical advice.
... The clinical implications of an accidental fall can be devastating in this patient population who are already multi-comorbid. Several prospective cohort studies conducted in HD patients have concluded that those who fell had a 2.1 to 3.5 times higher risk of admission to nursing homes, hospitalisation, and death [7,8]. Previous research has shown that factors such as older age, comorbidity, polypharmacy and frailty seem to be principal factors implicated in the aetiology of falls in these patients [1,2,4,7]. ...
Article
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Background: Stage 5 chronic kidney disease (CKD-5) patients on haemodialysis (HD) are at high risk of accidental falls. Previous research has shown that frailty is one of the primary contributors to the increased risk of falling in this clinical population. However, HD patients often present with abnormalities of cardiovascular function such as baroreflex impairment and orthostatic dysregulation of blood pressure (BP) which may also be implicated in the aetiology of falling. Therefore, we aimed to explore the relative importance of frailty and cardiovascular function as potential exercise-modifiable predictors of falls in these patients. Methods: Ninety-three prevalent CKD-5 patients on HD from three Renal Units were recruited for this prospective cohort study, which was conducted between October 2015 and August 2018. At baseline, frailty status was assessed using the Fried's frailty phenotype, while physical function was evaluated through timed up and go (TUG), five repetitions chair sit-to-stand (CSTS-5), objectively measured physical activity, and maximal voluntary isometric strength. Baroreflex and haemodynamic function at rest and in response to a 60° head-up tilt test (HUT-60°) were also assessed by means of the Task Force Monitor. The number of falls experienced was recorded once a month during 12 months of follow-up. Results: In univariate negative binomial regression analysis, frailty (RR: 4.10, 95%CI: 1.60-10.51, p = 0.003) and other physical function determinants were associated with a higher number of falls. In multivariate analysis however, only worse baroreflex function (RR: 0.96, 95%CI: 0.94-0.99, p = 0.004), and orthostatic decrements of BP to HUT-60° (RR: 0.93, 95%CI: 0.87-0.99, p = 0.033) remained significantly associated with a greater number of falls. Eighty falls were recorded during the study period and the majority of them (41.3%) were precipitated by dizziness symptoms, as reported by participants. Conclusions: This prospective study indicates that cardiovascular mechanisms implicated in the short-term regulation of BP showed a greater relative importance than frailty in predicting falls in CKD-5 patients on HD. A high number of falls appeared to be mediated by a degree of cardiovascular dysregulation, as evidenced by the predominance of self-reported dizziness symptoms. Trial registration: ClinicalTrials.gov (trial registration ID: NCT02392299; date of registration: March 18, 2015).
... Decreased physical functioning is common in dialysis [4][5][6][7][8][9][10][11][12]; is a strong predictor of increased mortality, morbidity, and healthcare utilization [10,[13][14][15][16][17]; and is itself an important patient-centered outcome [18,19] among patients receiving dialysis. However, recognition of poor physical functioning by dialysis providers is suboptimal [20]. ...
Article
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Background: Provider recognition of level of functioning may be suboptimal in the dialysis setting, and this lack of recognition may lead to less patient-centered care. We aimed to assess whether delivery of an app-based, individualized functioning report would improve patients' perceptions of patient-centeredness of care. Methods: In this pre-post pilot study at three outpatient dialysis facilities in metropolitan Atlanta, an individualized functioning report-including information on physical performance, perceived physical functioning, and community mobility-was delivered to patients receiving hemodialysis (n = 43) and their providers. Qualitative and quantitative approaches were used to gather patient and provider feedback to develop and assess the report and app. Paired t test was used to test for differences in patient perception of patient-centeredness of care (PPPC) scores (range, 1 = most patient-centered to 4 = least patient-centered) 1 month after report delivery. Results: Delivery of the reports to both patients and providers was not associated with a subsequent change in patients' perceptions of patient-centeredness of their care (follow-up vs. baseline PPPC scores of 2.35 vs. 2.36; P > 0.9). However, patients and providers generally saw the potential of the report to improve the patient-centeredness of care and reacted positively to the individualized reports delivered in the pilot. Patients also reported willingness to undergo future assessments. However, while two-thirds of surveyed providers reported always or sometimes discussing the reports they received, most (98%) participating patients reported that no one on the dialysis care team had discussed the report with them within 1 month. Conclusions: Potential lack of fidelity to the intervention precludes definitive conclusions about effects of the report on patient-centeredness of care. The disconnect between patients' and providers' perceptions of discussions of the report warrants future study. However, this study introduces a novel, individualized, multi-domain functional report that is easily implemented in the setting of hemodialysis. Our pilot study provides guidance for improving its use both clinically and in future pragmatic research studies, both within and beyond the dialysis population.
... The assessments were per-Nephron DOI: 10.1159/000501277 formed by the investigators (I.N.L. or N.A.G.) or by one of the trained research nurses. The GA consisted of validated questionnaires or structured assessments of 7 domains (Appendix 2): (ADL, Katz et al. [12]), instrumental ADL (IADL, Lawton and Brody [13]), mobility (Timed-Up-and-Go [14]), depressive symptoms (Geriatric Depression Scale [15], Appendix 4), nutrition (Mini Nutritional Assessment [16]), comorbidity burden (the Cumulative Illness Rating Scale-Geriatrics) [17,18] and cognition (Mini-Mental State Examination, [19] Clock drawing test, [20] fluency test [21] and enhanced cued recall test) [22]. Impaired cognition was defined as one or more impaired cognitive tests. ...
Article
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BACKGROUND AND OBJECTIVES: A geriatric assessment (GA) is a structural method for identifying frail patients. The relation of GA findings and risk of death in end-stage kidney disease (ESKD) is not known. The objective of the GA in OLder patients starting Dialysis Study was to assess the association of GA at dialysis initiation with early mortality and hospitalization. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Patients ≥65 years old were included just prior to dialysis initiation. All participants underwent a GA, including assessment of (instrumental) activities of daily living (ADL), mobility, cognition, mood, nutrition, and comorbidity. In addition, a frailty screening (Fried Frailty Index, [FFI]) was applied. Outcome measures were 6- and 12-month mortality, and 6-month hospitalization. Associations with mortality were assessed with cox-regression adjusting for age, sex, comorbidity burden, smoking, residual kidney function and dialysis modality. Associations with hospitalization were assessed with logistic regression, adjusting for relevant confounders. RESULTS: In all, 192 patients were included, mean age 75 ± 7 years, of whom 48% had ≥3 geriatric impairments and were considered frail. The FFI screening resulted in 46% frail patients. Mortality rate was 8 and 15% at 6- and 12-months after enrolment, and transplantation rate was 2 and 4% respectively. Twelve-month mortality risk was higher in patients with ≥3 impairments (hazard ratio [HR] 2.97 [95% CI 1.19-7.45]) compared to less impaired patients. FFI frail patients had a higher risk of 12-month mortality (HR 7.22 [95% CI 2.47-21.13]) and hospitalization (OR 1.93 [95% CI 1.00-3.72]) compared to fit patients. Malnutrition was associated with 12-month mortality, while impaired ADL and depressive symptoms were associated with 12-month mortality and hospitalization. CONCLUSIONS: Frailty as assessed by a GA is related to mortality in elderly patients with ESKD. Individual components of the GA are related to both mortality and hospitalization. As the GA allows for distinguishing between frail and fit patients initiating dialysis, it is potentially of added value in the decision-making process concerning dialysis initiation.
... Among ESRD elderly patients, prospective studies have confirmed that fall incidence (1.2-1.6 falls/person-year) is higher than reported rates for seniors residing in nursing homes (1.0-1.4 falls/resident-year) [52][53][54]. Falls are independently associated with increased mortality in elderly dialysis patients [55]. Some of the falls' risk factors are similar to those associated with functional decline, such as age, comorbidity, systolic blood pressure, prior falls, diabetes mellitus, polypharmacy, and mobility dependence [52,53]. ...
Chapter
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Older adults (aged ≥ 65 years) comprise the largest segment of the CKD population, and impaired kidney function is linked with unsuccessful aging. Individuals across the spectrum of kidney disease have clinical features of the frailty phenotype, suggesting that frailty is not confined to old age among vulnerable populations. This manifests as a high prevalence of impaired physical performance, emergent geriatric syndromes, disability, and risk of death. Considering the multiple system involvement underlying the symptoms and deficits seen in CKD, especially in the more severe stages, the concept of frailty is a highly useful tool to identify older adults with kidney disease who are on the trajectory of vulnerability leading to decline and death.
... Prospective cohort studies of HD patients, with a 12-month follow-up, report that 26.3% [3] to 47% [4] experience at least one fall per annum. Patients who fell were observed to be at increased risk of adverse outcomes such as admission to nursing homes, higher number and duration of hospitalisations [3] and death [5]. ...
Article
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Background Stage 5 chronic kidney disease patients on haemodialysis (HD) often present with dizziness and pre-syncopal events as a result of the combined effect of HD therapy and cardiovascular disease. The dysregulation of blood pressure (BP) during orthostasis may be implicated in the aetiology of falls in these patients. Therefore, we explored the relationship between baroreflex function, the haemodynamic responses to a passive orthostatic challenge, and falls in HD patients. Methods Seventy-six HD patients were enrolled in this cross-sectional study. Participants were classified as “fallers” and “non-fallers” and completed a passive head up tilting to 60o (HUT-60°) test on an automated tilt table. ECG signals, continuous and oscillometric BP measurements and impedance cardiography were recorded. The following variables were derived from these measurements: heart rate (HR) stroke volume (SV), cardiac output (CO), total peripheral resistance (TPR), number of baroreceptor events, and baroreceptor effectiveness index (BEI). Results The forty-four participants who were classified as fallers (57.9%) had a lower number of baroreceptor events (6.5±8.5 vs 14±16.7, p = .027) and BEI (20.8±24.2% vs 33.4±23.3%, p = .025). In addition, fallers experienced a significantly larger drop in systolic (-6.4±10.9 vs -0.4±7.7 mmHg, p = .011) and diastolic (-2.7±7.3 vs 1.8±6 mmHg, p = .027) oscillometric BP from supine to HUT-60° compared with non-fallers. None of the variables taken for the analysis were significantly associated with falls in multivariate logistic regression analysis. Conclusions This cross-sectional comparison indicates that, at rest, HD patients with a positive history of falls present with a lower count of baroreceptor sequences and BEI. Short-term BP regulation warrants further investigation as BP drops during a passive orthostatic challenge may be implicated in the aetiology of falls in HD.
... La valoración geriátrica [30][31][32][33] proporciona un abordaje global de la persona anciana mediante valoración clínica (con identificación de enfermedades crónicas y aspectos nutricionales), valoración funcional, valoración cognitiva, valoración psicosocial y fragilidad, cobrando cada vez más importancia en los pacientes con ERC 18 . En estos pacientes la evaluación y el tratamiento requiere de un abordaje multidisciplinar con estrategias que identifiquen factores de peor pronóstico que ayude en la toma de decisiones. ...
Article
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INTRODUCTION Conservative Management (CM) has become a therapeutic option in Advanced Chronic Kidney Disease in the elderly. However, there is a lack of evidence about prognosis of these patients in terms of survival and health related quality of life (HRQoL). OBJECTIVE Establish predictive variables associated with mortality and analyse HRQoL in CM patients. PATIENTS AND METHODS Prospective cohort study. An assessment of renal function parameters and a comprehensive geriatric assessment were made, including: analysis of comorbidity, functional, cognitive, fragility, nutritional, social and HRQoL status. RESULTS 82 patients with a mean age of 84 years and significant pluripathology were studied: 56% had history of vascular event and Charlson >8. The mortality rate was 23/1,000 patients per month, with a homogeneous mortality rate after 6 months. Survival differed significantly depending on whether they presented with a previous vascular event (36.7 vs. 14.8; p=0.028), Charlson score ≥10 (42 vs. 17; p=0.002), functional status (48.4 vs. 19; p=0.002) and fragility (27 vs. 10; p=0.05). Mortality predictors included eGFR and proteinuria, the presence of previous vascular events, Charlson comorbidity score, malnutrition-inflammation parameters (albumin and MNA score), degree of dependency, physical HRQoL and increase of PTH level. The presence of previous vascular event, comorbidity, decreased albumin and elevated PTH were independent predictors of mortality. HRQoL remained stable over time and no significant worsening occurred during treatment. CONCLUSIONS Having knowledge of the factors associated with mortality and HRQoL assessment can be a useful tool to helping decision making during CM. Previous vascular events, comorbidity, decreased albumin and increased PTH were independent predictors of mortality. Copyright © 2018 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.
... However, in such patients, the presence of SC increased the risk of overall mortality (Table 3). This might be explained based on consequences of syncope; for example, falling and accidents among patients undergoing dialysis [36,37]. Nevertheless, further research is required to verify this causality. ...
Article
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Objective: This study explored the impact of syncope and collapse (SC) on cardiovascular events and mortality in patients undergoing dialysis. Methods: Patients undergoing dialysis with SC (n = 3876) were selected as the study cohort and those without SC who were propensity score-matched at a 1:1 ratio were included as controls. Major adverse cardiovascular events (MACEs), including acute coronary syndrome (ACS), arrhythmia or cardiac arrest, stroke, and overall mortality, were evaluated and compared in both cohorts. Results: The mean follow-up periods until the occurrence of ACS, arrhythmia or cardiac arrest, stroke, and overall mortality in the SC cohort were 3.51 ± 2.90, 3.43 ± 2.93, 3.74 ± 2.97, and 3.76 ± 2.98 years, respectively. Compared with the patients without SC, those with SC had higher incidence rates of ACS (30.1 vs. 24.7 events/1000 people/year), arrhythmia or cardiac arrest (6.75 vs. 3.51 events/1000 people/year), and stroke (51.6 vs. 35.7 events/1000 people/year), with higher overall mortality (127.7 vs. 77.9 deaths/1000 people/year). The SC cohort also had higher risks for ACS, arrhythmia or cardiac arrest, stroke, and overall mortality (adjusted hazard ratios: 1.28 (95% confidence interval (CI) = 1.11–1.46), 2.05 (95% CI = 1.50–2.82), 1.48 (95% CI = 1.33–1.66), and 1.79 (95% CI = 1.67–1.92), respectively) than did the non-SC cohort. Conclusion: SC was significantly associated with cardiovascular events and overall mortality in the patients on dialysis. SC may serve as a prodrome for cardiovascular comorbidities, thereby assisting clinicians in identifying high-risk patients.
... Nevertheless, falls in general are subsequently associated with greater mortality and morbidity. 13,37 If the study findings hold true then it may impact many more people who have non-injurious falls/syncope at home, work, or outpatient settings and were not considered serious enough to present to the emergency department or hospital. ...
Article
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Introduction: With the growing emphasis on intensive blood pressure control, the potential for overtreatment and treatment-related adverse outcomes has become an area of interest. A large representative population within a real-world clinical environment with successful hypertension control rates was used to evaluate serious falls and syncope in people with low-treated systolic blood pressure (SBP). Methods: A cross-sectional study among medically treated hypertensive individuals within the Kaiser Permanente Southern California health system (2014-2015) was performed. Serious fall injuries and syncope were identified using ICD codes based on emergency department and hospitalization diagnoses. SBPs in a 1-year window were used to compare serious falls and syncope among individuals with SBP <110 mmHg vs ≥110 mmHg. Logistic regression was used to evaluate the association between low minimum and mean SBP and serious falls/syncope after adjustment for demographics, comorbidities, and medications. Results: In 477,516 treated hypertensive individuals, the mean age was 65 (SD=13) years and the mean SBP was 129 (SD=10) mmHg, with 27% having a minimum SBP <110 mmHg and 3% having mean SBP <110 mmHg. A total of 15,419 (3.2%) individuals experienced a serious fall or syncope or both during the observation window (5.7% among minimum SBP <110 mmHg and 5.4% among mean SBP <110 mmHg). The multivariable ORs for serious falls/syncope were 2.18 (95% CI=2.11, 2.25) for minimum SBP <110 mmHg and 1.54 (95%CI=1.43, 1.66) for mean SBP <110 mmHg compared with SBP ≥110 mmHg. Conclusions: Among treated hypertensive patients, both minimum and mean SBP less than 110 mmHg were associated with serious falls and syncope. Low treatment-related blood pressures deserve consideration given the emphasis on intensive blood pressure control.
... In a review published in 2010, Brown and Johansson [5] suggested that frailty may be a more meaningful predictor of important outcomes than age due to the stronger correlation with 1-year mortality and hospitalizations, consistent with the idea that frailty encompasses a more comprehensive portrait of an individual than age or comorbidity alone [6]. These associations with poor outcomes have also been observed among dialysis patients [6][7][8]. ...
Article
Purpose of review: Frailty is highly prevalent in the dialysis population and is associated with mortality. Recent studies have suggested that other dialysis outcomes are compromised in frail individuals. While we do not yet have a consensus as to the best measure of frailty, identification of these poor outcomes and their magnitude of association with frailty will help improve prognostication, allow for earlier interventions, and improve provider-to-patient communication. Recent findings: The most widely used assessment of frailty is Fried's physical performance criteria. However, regardless of assessment method, frailty remains highly associated with mortality. More recently, frailty has been associated with falls, fractures, cognitive impairment, vascular access failure, and poor quality of life. Recent large cohort studies provide strong evidence that frailty assessment can provide important prognostic information for providers and patients both before and after initiation of dialysis. Trials aimed at improving frailty are limited and show the promise of augmenting quality of life, although more studies are needed to firmly establish mortality benefits. Summary: We underscore the importance of frailty as a prognostic indicator and identify other recently established consequences of frailty. Widespread adoption of frailty assessment remains limited and researchers continue to find ways of simplifying the data collection process. Timely and regular assessment of frailty may allow for interventions that can mitigate the onset of poor outcomes and identify actionable targets for dialysis providers.
... The assessments were performed by the primary investigator (I.N.v.L.) or one of the trained re-search nurses. The geriatric assessment consisted of validated questionnaires or a structured assessment of the following seven domains (Tables 1 and 2): activities of daily living (Katz et al. [27]), instrumental activities of daily living (Lawton and Brody [28]), mobility (Timed-Up-and-Go [29]; the average of three measurements was recorded), depressive symptoms (the Geriatric Depression Scale [30]), nutrition (the Mini Nutritional Assessment [31]), comorbidity burden (the Cumulative Illness Rating Scale-Geriatrics [32]), and cognition. The cognitive test battery consisted of four tests: the Mini Mental State Examination (33), the Enhanced Cued Recall (34), the Clock drawing test (35), and fluency (36). ...
Article
Background and objectives: A geriatric assessment is an appropriate method for identifying frail elderly patients. In CKD, it may contribute to optimize personalized care. However, a geriatric assessment is time consuming. The purpose of our study was to compare easy to apply frailty screening tools with the geriatric assessment in patients eligible for dialysis. Design, setting, participants, & measurements: A total of 123 patients on incident dialysis ≥65 years old were included <3 weeks before to ≤2 weeks after dialysis initiation, and all underwent a geriatric assessment. Patients with impairment in two or more geriatric domains on the geriatric assessment were considered frail. The diagnostic abilities of six frailty screening tools were compared with the geriatric assessment: the Fried Frailty Index, the Groningen Frailty Indicator, Geriatric8, the Identification of Seniors at Risk, the Hospital Safety Program, and the clinical judgment of the nephrologist. Outcome measures were sensitivity, specificity, positive predictive value, and negative predictive value. Results: In total, 75% of patients were frail according to the geriatric assessment. Sensitivity of frailty screening tools ranged from 48% (Fried Frailty Index) to 88% (Geriatric8). The discriminating features of the clinical judgment were comparable with the other screening tools. The Identification of Seniors at Risk screening tool had the best discriminating abilities, with a sensitivity of 74%, a specificity of 80%, a positive predictive value of 91%, and a negative predictive value of 52%. The negative predictive value was poor for all tools, which means that almost one half of the patients screened as fit (nonfrail) had two or more geriatric impairments on the geriatric assessment. Conclusions: All frailty screening tools are able to detect geriatric impairment in elderly patients eligible for dialysis. However, all applied screening tools, including the judgment of the nephrologist, lack the discriminating abilities to adequately rule out frailty compared with a geriatric assessment.
... Previous reports showed that falls can be markers of poor health and declining function, and are often associated with significant morbidity and mortality in HD population (Li et al., 2008). It has been shown that a cut-off score of 16 s or more during the TUG predicts falls in older subjects (Okumiya et al., 1998). ...
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Background: Tunisia has the highest prevalence of hemodialysis patients compared to the other countries in North Africa. Dialysis centers rarely offer an exercise program to prevent physiological and psychological dialysis therapy-related alterations in chronic hemodialysis patients. Aim: To examine the effect of combined endurance-resistance training program on physiological and psychological outcomes in patients undergoing hemodialysis. Methods: We designed a single blinded, randomized, controlled study for a period of 4 months. Patients were randomized to intervention group or control group. Intervention group patients received 4 training sessions per week, held on non-hemodialysis days for a period of 4 months, whereas control group patients continued their regular lifestyle practice without direct intervention from the personnel of this investigation. Patients were evaluated at baseline (initial assessment) and after the four-month study period (final assessment) by the same investigator blinded to treatment group assignment using physical, physiological, and psychological measurements. Results: Compared with control group, intervention group showed significant improvement in physical performance during the sit-to-stand-to-sit tests (STS-10: −16.2%, ES = −1.65; STS-60: +23.43%, ES = 1.18), handgrip force task (+23.54%, ES = 1.16), timed up and go test (−13.86%, ES = −1.13), and 6-min walk test (+15.94%, ES = 2.09). Likewise, mini nutritional assessment long form scores after intervention period were significantly higher in the intervention group compared to the control group (ES = 1.43). Physical and mental component scores of SF-36 questionnaire increased significantly in the intervention group (ES = 1.10 and ES = 2.06, respectively), whereas hospital anxiety and depression scale scores decreased significantly (ES = −1.65 and ES = −2.72, respectively). Regarding biological parameters, intervention group displayed improvement in systolic and diastolic blood pressures (ES = −2.77 and ES = −0.87, respectively), HDL-cholesterol, LDL-cholesterol, and triglycerides systematic levels (ES = 1.15, ES = −0.98, and ES = −1.01, respectively); however no significant effect of intervention period was observed on C-reactive protein, hemoglobin, albumin, and total cholesterol levels (P > 0.05). Conclusion: The current study showed that combined endurance-resistance training program had a beneficial effect on physical capacity and quality of life in chronic hemodialysis patients.
... Patient preference was a key criterion underlining the significance of shared decision making. In particular, frailty is associated with poor outcomes in haemodialysis patients [7,[22][23][24]. Also, favourable results have been reported, especially for patients participating in geriatric rehabilitation programmes [8,[25][26][27][28][29]. ...
Chapter
End-stage kidney disease (ESKD) is an extremely complex chronic condition requiring nuanced attention to patient care and medication management. This specialized patient population requires intentional coordination among multidisciplinary care team members who are focused on enhancing patient-centered care with a shared goal of improving clinical outcomes. Renal-specific medication management is a major area of opportunity for ESKD patients who often take several different medications from multiple providers due, in part, to other co-existing health conditions. Deteriorated kidney functioning and the need to undergo frequent dialysis sessions further confound medication dosing and administration timing. With proper education, oversight and clinical pharmacist support, potential medication-related problems can be identified proactively, helping to avert unnecessary hospitalizations, excess healthcare costs, patient morbidity and mortality, and reduced quality of life.
Chapter
There is a large and growing geriatric population in patients with end-stage kidney disease (ESKD) requiring renal replacement therapy. Among incident ESKD patients, those older than age 75 years outnumber those aged 65–74 and have the highest incident growth rate. Contributing factors include increased prevalence of diabetes mellitus and hypertension, improved life expectancy, and increased willingness to initiate dialysis therapy in the older population. There are many geriatric considerations that must be taken into account when caring for older patients with ESKD. These include traditional geriatric syndromes (e.g., frailty, falls, cognitive impairment) along with renal specific considerations, such as renal replacement treatment modality and access considerations. Having an approach to these issues is essential to providing optimal, comprehensive care to older adults with renal disease.
Thesis
La plasticité du muscle strié squelettique lui permet de s’adapter de façon optimale aux stimuli de son environnement comme l’exercice, mais le rend aussi sensible à des conditions délétères comme le manque d’activité physique et les maladies chroniques qui vont souvent de pair. Dans le cadre de l’insuffisance rénale chronique terminale, la fonction musculaire, fortement affectée, peut être améliorée par l’exercice physique pratiqué pendant l’hémodialyse. Ce travail de thèse a permis de mettre en évidence que quelle que soit la séquence des exercices, la réhabilitation combinée permet d’améliorer la force des membres, la vitesse de marche et l’équilibre des patients. Ce travail de thèse montre aussi l’intérêt de l’implémentation de l’exercice excentrique au lit du patient qui pourrait permettre dans le futur une réhabilitation encore plus efficace et également accessible aux plus déconditionnés. Parallèlement, le développement de stratégies thérapeutiques efficaces requiert l’identification des mécanismes moléculaires impliqués dans la régulation de la balance protéique musculaire. De nombreuses voies de signalisation cellulaires permettent de réguler la synthèse et la dégradation des protéines et le facteur eIF3f apparait comme un régulateur majeur de la synthèse protéique. Dans ce travail de thèse, l’étude des fonctions physiologiques de eIF3f chez l’animal a permis de montrer in vivo l’impact du niveau d’expression de eIF3f sur la régulation de la masse musculaire et de la synthèse protéique à l’état basal et en condition d’hypoactivité. Alors que sa sous-expression diminue la masse du tissu musculaire et affecte le métabolisme, sa surexpression stimule l’anabolisme et permet de retarder l’atrophie musculaire induite par l’immobilisation. La compréhension des rôles physiologiques de eIF3f dans le maintien de la fonction musculaire pourrait alors permettre le développement de nouvelles thérapeutiques du déconditionnement musculaire.
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Objectives: Geriatrician impact on patient and system outcomes in formal rehabilitation settings has not been well described to date. We studied the effect of adding a geriatric medicine consultation service to a geriatric focused rehabilitation setting providing care to dialysis and non-dialysis patients. Design/setting/participants: A pre- and post-retrospective observational cohort study from January 1, 2009 to June 30, 2019 on all consecutively admitted adults aged 65 and older to general rehabilitation program, and adults aged 60 and older to specialized dialysis rehabilitation program, within a 25 bed general rehabilitation unit in a large urban academic rehabilitation center in Toronto, Ontario. Data were analyzed with quality improvement methodology including Statistical Process Control charts (XmR and U charts). Intervention: Addition of a geriatric medicine service providing automatic comprehensive geriatric assessment and co-management consultative services for all admitted patients from admission onwards who met criteria for the intervention. The intervention commenced on August 1, 2013. Measurements: Outcome measures were length of stay (days), service interruption frequency, and average functional independence measure (FIM) change (discharge FIM minus admission FIM) which uses the validated FIM score, a marker of functional ability. A 22 point change in FIM score is clinically relevant. Results: Patient characteristics: general rehabilitation patients (n = 1395, mean age = 79.7, 50.1% female) and dialysis rehabilitation patients (n = 838, mean age = 72.8, 41.8% female). The average FIM change following intervention improved from 20.8 to 29.3 in the general rehabilitation cohort (40.6% improvement, SD = 5.51) and from 22.1 to 30.6 in the dialysis rehabilitation cohort (38.6% improvement, SD = 5.88). Changes in length of stay (24.9%-28.1% reduction) and service interruption frequency (34.3%-49.7% reduction) were also observed. Conclusion: Introduction of a geriatric medicine service for rehabilitation inpatients was associated with significant FIM score improvements. Our results suggest this intervention contributes to important gains in functional independence in reduced time for older adults receiving inpatient rehabilitative care.
Chapter
Chronic kidney disease (CKD) is associated with high rates of fracture, cardiovascular events, and mortality. The pathophysiology is complex, including reduced levels of Klotho and active vitamin D, and markedly elevated levels of fibroblastic growth factor 23 and parathyroid hormone. Abnormal Wnt and activin signaling pathways influence the maturation of bone and vascular smooth muscle cells. These changes play important roles in the early development of the bone disorders and heightened cardiovascular risk of patients with CKD. Bones are also impacted by acidosis, abnormalities in circulating hormones, accumulation of toxic substances, and poor muscle strength. In addition to fractures, patients manifest bone pain and extraskeletal calcifications that are related to the bone disease in complex ways. Diagnostic tests such as bone density, histology, radiology, and biochemical markers are useful but all have limitations. There is inadequate data from clinical trials to guide treatment of the fragile bones in CKD patients. Treatments to attain normal turnover and improve bone mineralization may be beneficial. Standard therapies used for osteoporosis must be carefully targeted because inappropriate use of these treatments may be unsafe or ineffective.
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The poor health outcomes of Renal Replacement Therapy (RRT) in the elderly has promoted Conservative Management (CM) as a therapeutic option in advanced chronic kidney disease. However, there is still a lack of evidence about prognosis of these patients; thus, the aim was to analyze the survival rate of elderly patients under CM and RRT and evaluate the variables related to the initiation of such treatments in clinical practice. Methods: Prospective cohort study of RRT and CM patients >75años. Renal function parameters and geriatric assessments were carried out. This evaluation included: analysis of comorbidity, functional, cognitive, frailty, nutritional and socio-family status. Results: Cohort of 37 RRT and 82 CM patients. CM patients were significantly older, with more frequency of history of vascular event, more comorbility (Charlson), worse functional situation (Barthel), higher risks of cognitive impairment (Pfeiffer) and malnutrition (MNA-SF), and higher frailty and socio-familiar impairment. Mortality rate was lower in RRT patients (8.72 vs. 3/1,000 patients/month; HR= 0.37, p=0.018), but survival advantage reduced drastically after adjustment for the different geriatric syndromes analyzed. Conclusions: Charlson's comorbidity was found to be an independent mortality predictor in elderly patients with advanced chronic kidney disease. Dialysis did not improve survival with respect to conservative treatment in patients with Charlson higher than 8 points.
Chapter
The chronic kidney disease (CKD) population is older, with common comorbidities such as diabetes, hypertension, and cardiovascular disease (CVD). Frailty, low levels of physical function, and low levels of physical activity are related to morbidity and mortality and are well documented in people with CKD. Obesity is common; however, sarcopenic obesity is increasingly recognized. Although physical activity is generally recognized as important, self-perception of actual activity levels is often overstated. Physical activity and exercise should be the core components of the management of people with CKD.
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The association between serious falls and dialysis modality [hemodialysis (HD) and peritoneal dialysis (PD)] is unclear. A nationwide population-based retrospective cohort study with 127,823 end-stage renal disease patients aged over 18 years was conducted with the unmatched cohort of 101,304 HD and 7,584 PD patients retrieved from Taiwan’s National Health Insurance Research Database during 2000–2013. A total of 7,584 HD and 7,584 PD patients matched at 1:1 ratio by propensity score were enrolled to the study. Serious falls were defined by the diagnostic codes, E code, and image studies. Cox regression model and competing-risk model were used for statistical analysis. HD patients were older and had more comorbidities at baseline than PD patients. After matching and adjustment, HD patients had a higher risk of serious falls than PD patients [sHR 1.27 (95% CI 1.06–1.52)]. Females, elders, a history of falls before dialysis, comorbidity with stroke or visual problems, using diuretics, α-blockers, and mydriatics were associated with higher risks of serious falls among dialysis patients. The risk of serious falls was higher in HD patients than PD patients. Health professionals should create age-friendly environments, reduce unnecessary medications, and raise patients’ awareness of falls in daily life.
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Background: As the numbers of older patients on dialysis rise, geriatric problems such as falling become more prevalent. We aimed to assess the prevalence of falls and the impact on mortality and quality of life in frail elderly patients on assisted PD (aPD) and hemodialysis (HD) from the FEPOD Study. Methods: Data on falls and quality of life were collected with questionnaires at baseline and every six months during 2-year follow-up. Multiple regression analysis was used to evaluate factors associated with falls. Additionally, we performed a review of literature concerning the relation between falls and poor outcome. Results: Baseline fall data were available for 203 patients and follow-up data for 114 patients. Dialysis modality was equally distributed (49% HD and 51% aPD). Mean (SD) age was 75 ± 7 years. Fall rate was 1.00 falls/patient year, comparable in HD and aPD. Falls led to fear of falling, resulting in less activities in 68% vs 42% (p < 0.01) and leaving the house less in 59% vs 31% (p < 0.01) of patients. Patients with diabetes mellitus were twice as likely to report falls at baseline (OR 1.91 [95%CI 1.00-3.63], p = 0.05) and falls at baseline were associated with falls during follow-up (OR 2.53 [95%CI 1.06-6.04] p = 0.03). Literature revealed frailty was a strong risk factor for falling and falling results in a higher mortality and hospitalization rate. Conclusion: Falls were frequent in older dialysis patients and have a negative impact on quality of life. Fall incidence is comparable between aPD and HD.
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Background: The prognostic impact of nutrition and chronic kidney disease (CKD) complications has already been described in elderly haemodialysis patients but their relative weights on risk of death remain uncertain. Using structural equation models (SEMs), we aimed to model a single variable for nutrition, each CKD complication and cardiovascular comorbidities to compare their relative impact on elderly haemodialysis patients' survival. Methods: This prospective study recruited 3165 incident haemodialysis patients ≥75 years of age from 178 French dialysis units. Using SEMs, the following variables were computed: nutritional status, anaemia, mineral and bone disorder and cardiovascular comorbidities. Systolic blood pressure was also used in the analysis. Survival analyses used Poisson models. Results: The population average age was 81.9 years (median follow-up 1.51 years, 35.5% deaths). All variables were significantly associated with mortality by univariate analysis. Nutritional status was the variable most strongly associated with mortality in the multivariate analysis, with a negative prognostic impact of low nutritional markers {incidence rate ratio [IRR] 1.42 per 1 standard deviation [SD] decrement [95% confidence interval (CI) 1.32-1.53]}. The 'cardiovascular comorbidities' variable was the second variable associated with mortality [IRR 1.19 per 1 SD increment (95% CI 1.11-1.27)]. A trend towards low intact parathyroid hormone and high serum calcium and low values of systolic blood pressure were also associated with poor survival. The variable 'anaemia' was not associated with survival. Conclusions: These findings should help physicians prioritize care in elderly haemodialysis patients with CKD complications, with special focus on nutritional status.
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【Purpose】The purpose of this study was to examine the assessment items related to independent walking in chronic kidney disease (CKD) patients. 【Methods】This was a cross-sectional study that included 70 inpatients with stage 4 to 5 CKD. The patients were divided into an independent walking group and a dependent walking group. Logistic regression analysis based on the patient characteristics, blood test data, and physical function was performed, and the cut-off values were calculated. 【Results】 The identified assessment items and their respective cut-off values were as follows: knee extension strength (KES) to body weight ratio, 30.5%; and one-leg standing time (OLST), 2.7 s. 【Conclusion】This study revealed that the KES and OLST were related to independent walking ability in CKD patients. These assessments are necessary to evaluate whether independent walking is possible.
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Greater focus on patient‐reported outcome measures for dialysis patients and an increased patient engagement focus has highlighted a lack of formal patient‐generated strategies. Patient‐to‐patient peer mentoring is one approach that may improve the outcomes for people receiving dialysis. This review aims to synthesize quantitative and qualitative studies investigating dialysis‐associated patient‐to‐patient peer mentor support among adults with chronic kidney disease and end stage kidney disease. Research studies describe the benefits of peer mentor programs in dialysis to include: improved goal setting, decision‐making and increased self‐management. While a variety of program formats exist, a combination of face‐to‐face and telephone peer support models are recommended and formal training of mentors is required. In addition, the formal support of dialysis clinicians, nephrologists and administrators is vital for the success of a dialysis patient‐to‐patient peer mentor program.
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Currently, older adults comprise nearly one‐third of prevalent US dialysis patients, and this proportion will increase as the population ages. Older dialysis patients experience greater morbidity and mortality than nondialysis patients of the same age, and in part, it is related to progressive functional decline. Progressive functional decline, characterized by need for assistance with more than 2 activities of daily living, contributes to risk of hospitalization, further functional decline, and subsequent nursing home placement when a patient no longer functions independently at home. Progressive functional decline may appear to be unavoidable for older dialysis patients; however, comprehensive geriatric assessment (CGA) may alleviate the prevalence and severity of functional decline. This editorial summarizes common risk factors of functional decline and introduces CGA as a potentially transformative approach to breaking the cycle of functional decline in older dialysis patients.
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In recent decades, life expectancy has significantly extended, and the number of elderly people in each population increases significantly during the subsequent years. Ageing is associated with a physiological deterioration of kidney function, however, in patients with additional diseases such as diabetes, hypertension and obesity, there is often stronger severity of kidney damage. It has been estimated that the prevalence of chronic kidney disease (CKD) in the older population is several times higher than in the general population. It is considered that in addition to the mentioned above comorbid the socio-economic factors also increases prevalence of CKD. The occurrence of CKD significantly increases the mortality, deteriorating the quality of life of these subjects and is also severe financial problem for the health care system because of the high costs of renal replacement therapy. For this reason, renal replacement therapy in elderly patients is expensive and not always brings measurable benefits.
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There is disagreement on the usefulness of comprehensive geriatric assessment (CGA) due to conflicting results from individual trials. We did a meta-analysis on 28 controlled trials comprising 4959 subjects allocated to one of five CGA types and 4912 controls. Published data were supplemented with reanalysed data provided by the original investigators. We calculated combined odds ratios of important outcomes by pooling data from individual trials with multivariate logistic regression. Combined odds ratio (95% confidence interval) of living at home at follow-up was 1.68 (1.17-2.41) for geriatric evaluation and management units, 1.49 (1.12-1.98) for hospital-home assessment services, and 1.20 (1.05-1.37) for home assessment services. Covariate analysis showed that programmes with control over medical recommendations and extended ambulatory follow-up were more likely to be effective. Our analysis suggests that CGA programmes linking geriatric evaluation with strong long-term management are effective for improving survival and function in older persons.
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Falls warrant investigation as a risk factor for nursing home admission because falls are common and are associated with functional disability and because they may be preventable. We conducted a prospective study of a probability sample of 1103 people over 71 years of age who were living in the community. Data on demographic and medical characteristics, use of health care, and cognitive, functional, psychological, and social functioning were obtained at base line and one year later during assessments in the participants' homes. The primary outcome studied was the number of days from the initial assessment to a first long-term admission to a skilled-nursing facility during three years of follow-up. Patients were assigned to four categories during follow-up: those who had no falls, those who had one fall without serious injury, those who had two or more falls without serious injury, and those who had at least one fall causing serious injury. A total of 133 participants (12.1 percent) had long-term admissions to nursing homes. In an unadjusted model, the risk of admission increased progressively, as compared with that for the patients with no falls, for those with a single noninjurious fall (relative risk, 4.9; 95 percent confidence interval, 3.2 to 7.5), those with multiple noninjurious falls (relative risk, 8.5; 95 percent confidence interval, 3.4 to 21.2), and those with at least one fall causing serious injury (relative risk, 19.9; 95 percent confidence interval, 12.2 to 32.6). Adjustment for other risk factors lowered these ratios to 3.1 (95 percent confidence interval, 1.9 to 4.9) for one noninjurious fall, 5.5 (95 percent confidence interval, 2.1 to 14.2) for two or more noninjurious falls, and 10.2 (95 percent confidence interval, 5.8 to 17.9) for at least one fall causing serious injury, but the association between falls and admission to a nursing home remained strong and significant. The population attributable risk of long-term admission to a nursing home for these three groups (the proportion of admissions directly attributable to the three categories of falls) was 13 percent, 3 percent, and 10 percent, respectively. Among older people living in the community falls are a strong predictor of placement in a skilled-nursing facility; interventions that prevent falls and their sequelae may therefore delay or reduce the frequency of nursing home admissions.
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Functional decline in physically frail, elderly persons is associated with substantial morbidity. It is uncertain whether such functional decline can be prevented. We randomly assigned 188 persons 75 years of age or older who were physically frail and living at home to undergo a six-month, home-based intervention program that included physical therapy and that focused primarily on improving underlying impairments in physical abilities, including balance, muscle strength, ability to transfer from one position to another, and mobility, or to undergo an educational program (as a control). The primary outcome was the change between base line and 3, 7, and 12 months in the score on a disability scale based on eight activities of daily living: walking, bathing, upper- and lower-body dressing, transferring from a chair, using the toilet, eating, and grooming. Scores on the scale ranged from 0 to 16, with higher scores indicating more severe disability. Participants in the intervention group had less functional decline over time, according to their disability scores, than participants in the control group. The disability scores in the intervention and control groups were 2.3 and 2.8, respectively, at base line; 2.0 and 3.6 at 7 months (P=0.008 for the comparison between the groups in the change from base line); and 2.7 and 4.2 at 12 months (P=0.02). The benefit of the intervention was observed among participants with moderate frailty but not those with severe frailty. The frequency of admission to a nursing home did not differ significantly between the intervention group and the control group (14 percent and 19 percent, respectively; P=0.37). A home-based program targeting underlying impairments in physical abilities can reduce the progression of functional decline among physically frail, elderly persons who live at home.
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Preventing the development of disability in activities of daily living is an important goal in older adults, yet relatively little is known about the disabling process. To evaluate the relationship between 2 types of intervening events (hospitalization and restricted activity) and the development of disability and to determine whether this relationship is modified by the presence of physical frailty. Prospective cohort study, conducted in the general community in greater New Haven, Conn, from March 1998 to March 2003, of 754 persons aged 70 years or older, who were not disabled (ie, required no personal assistance) in 4 essential activities of daily living: bathing, dressing, walking inside the house, and transferring from a chair. Participants were categorized into 2 groups according to the presence of physical frailty (defined on the basis of slow gait speed) and were followed up with monthly telephone interviews for up to 5 years to ascertain exposure to intervening events and determine the occurrence of disability. Disability, defined as the need for personal assistance in bathing, dressing, walking inside the house, or transferring from a chair. During the 5-year follow-up period, disability developed among 417 (55.3%) participants, 372 (49.3%) were hospitalized and 600 (79.6%) had at least 1 episode of restricted activity. The multivariable hazard ratios for the development of disability were 61.8 (95% confidence interval [CI], 49.0-78.0) within a month of hospitalization and 5.54 (95% CI, 4.27-7.19) within a month of restricted activity. Strong associations were observed for participants who were physically frail and those who were not physically frail. Hospital admissions for falls were most likely to lead to disability. Intervening events occurring more than a month prior to disability onset were not associated with the development of disability. The population-attributable fractions associated with new exposure to hospitalization and restricted activity, respectively, were 0.48 and 0.19; 0.40 and 0.20, respectively, for frail participants and 0.61 and 0.16, respectively, for nonfrail participants. Illnesses and injuries leading to either hospitalization or restricted activity represent important sources of disability for older persons living in the community, regardless of the presence of physical frailty. These intervening events may be suitable targets for the prevention of disability.
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Dialysis patients are increasingly older and more disabled. In community-dwelling seniors without kidney disease, falls commonly predict hospitalization, the onset of frailty, and the need for institutional care. Effective fall prevention strategies are available. On the basis of retrospective data, it was hypothesized that the fall rates of older (> or =65 yr) chronic outpatient hemodialysis (HD) patients would be higher than published rates for community-dwelling seniors (0.6 to 0.8 falls/patient-year). It also was hypothesized that risk factors for falls in dialysis outpatients would include polypharmacy, dialysis-related hypotension, cognitive impairment, and decreased functional status. Using a prospective cohort study design, HD patients who were > or =65 yr of age at a large academic dialysis unit were recruited. All study participants underwent baseline screening for fall risk factors. Patients were followed prospectively for a minimum of 1 yr. Falls were identified through biweekly patient interviews in the HD unit. A total of 162 patients (mean age 74.7 yr) were recruited; 57% were male. A total of 305 falls occurred in 76 (47%) patients over 190.5 person-years of follow-up (fall-incidence 1.60 falls/person-year). Injuries occurred in 19% of falls; 41 patients had multiple falls. Associated risk factors included age, comorbidity, mean predialysis systolic BP, and a history of falls. In the HD population, the fall risk is higher than in the general community, and fall-related morbidity is high. Better identification of HD patients who are at risk for falls and targeted fall intervention strategies are required.
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Over the past decade, there has been a steep rise in the number of people with complex medical problems who require dialysis. We sought to determine the life expectancy of elderly patients after starting dialysis and to identify changes in survival rates over time. All patients aged 65 years or older who began dialysis in Canada between 1990 and 1999 were identified from the Canadian Organ Replacement Register. We used Cox proportional hazards models to examine the effect that the period during which dialysis was initiated (era 1, 1990-1994; era 2, 1995-1999) had on patient survival, after adjusting for diabetes, sex and comorbidity. Patients were followed from initiation of dialysis until death, transplantation, loss to follow-up or study end (Dec. 31, 2004). A total of 14,512 patients aged 65 years or older started dialysis between 1990 and 1999. The proportion of these patients who were 75 years or older at the start of dialysis increased from 32.7% in era 1 (1990-1994) to 40.0% in era 2 (1995-1999). Despite increased comorbidity over the 2 study periods, the unadjusted 1-, 3- and 5-year survival rates among patients aged 65-74 years at dialysis initiation rose from 74.4%, 44.9% and 25.8% in era 1 to 78.1%, 51.5% and 33.5% in era 2. The respective survival rates among those aged 75 or more at dialysis initiation increased from 67.2%, 32.3% and 14.2% in era 1 to 69.0%, 36.7% and 20.3% in era 2. This survival advantage persisted after adjustment for diabetes, sex and comorbidity in both age groups (65-74 years: hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.72- 0.81; 75 years or more: HR 0.86, 95% CI 0.80-0.92). Survival after dialysis initiation among elderly patients has improved from 1990 to 1999, despite an increasing burden of comorbidity. Physicians may find these data useful when discussing prognosis with elderly patients who are initiating dialysis.
Article
The objective of this study was to develop a prospectively applicable method for classifying comorbid conditions which might alter the risk of mortality for use in longitudinal studies. A weighted index that takes into account the number and the seriousness of comorbid disease was developed in a cohort of 559 medical patients. The 1-yr mortality rates for the different scores were: "0", 12% (181); "1-2", 26% (225); "3-4", 52% (71); and "greater than or equal to 5", 85% (82). The index was tested for its ability to predict risk of death from comorbid disease in the second cohort of 685 patients during a 10-yr follow-up. The percent of patients who died of comorbid disease for the different scores were: "0", 8% (588); "1", 25% (54); "2", 48% (25); "greater than or equal to 3", 59% (18). With each increased level of the comorbidity index, there were stepwise increases in the cumulative mortality attributable to comorbid disease (log rank chi 2 = 165; p less than 0.0001). In this longer follow-up, age was also a predictor of mortality (p less than 0.001). The new index performed similarly to a previous system devised by Kaplan and Feinstein. The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death from comorbid disease for use in longitudinal studies. Further work in larger populations is still required to refine the approach because the number of patients with any given condition in this study was relatively small.
Article
La fragilite est un concept nouveau, controverse et enigmatique. Les chercheurs, les decideurs ainsi que les prestataires de soins de sante ont constate l'impact de la fragilite sur les personnes atteintes, sur leur famille, notamment sur les soignants, et sur la societe. Au cours des deux dernieres decennies, la documentation traitant de la fragilite s'est fait de plus en plus abondante. Toutefois, il n'existe toujours pas de definition et de criteres universellement reconnus pour decrire la fragilite, et il y a peu d'informations concernant la qualite des resultats de recherche ayant trait au concept. L'Initiative canadienne sur la fragilite et le vieillissement a ete mise en oeuvre afin de favoriser une meilleure comprehension des causes, des consequences et de la trajectoire de la fragilite. Elle a aussi pour but d'accroitre la qualite de vie des personnes âgees a risques de devenir fragiles par la diffusion d'informations sur la prevention, le depistage et le traitement de la fragilite ainsi que sur l'organisation efficace des services. La premiere phase de l'Initiative consiste a effectuer une vaste revue systematique de la litterature sur la fragilite afin de faire la synthese de l'etat actuel de la recherche en vue d'elaborer un modele provisoire et d'etablir les priorites de recherche qui pourraient etre utilisees pour l'elaboration d'un programme de recherche. Le modele provisoire de la fragilite se veut integrative tenant compte des facteurs biologiques, sociaux, cliniques, psychologiques et environnementaux qui interagissent tout au long de la vie d'une personne et qui peuvent faire en sorte qu'elle vieillisse ou non sainement, retardant ou favorisant l'apparition de la fragilite.
Article
SUMMARY Nonproportional hazards can often be expressed by extending the Cox model to include time varying coefficients; e.g., for a single covariate, the hazard function for subject i is modelled as exp {β(t)Zi(t)}. A common example is a treatment effect that decreases with time. We show that the function βi(t) can be directly visualized by smoothing an appropriate residual plot. Also, many tests of proportional hazards, including those of Cox (1972), Gill & Schumacher (1987), Harrell (1986), Lin (1991), Moreau, O'Quigley & Mesbah (1985), Nagelkerke, Oosting & Hart (1984), O'Quigley & Pessione (1989), Schoenfeld (1980) and Wei (1984) are related to time-weighted score tests of the proportional hazards hypothesis, and can be visualized as a weighted least-squares line fitted to the residual plot.
Article
General practice p 994 Older people frequently fall. This is a serious public health problem, with a substantial impact on health and healthcare costs.1 These guidelines translate trial evidence about prevention of falls into recommendations that can be implemented in different settings, with the aim of reducing the rate of falls and injurious falls in people over 65 (see boxes 2 3). Summary points Multifaceted interventions reduce falls in older people (those over 65) Home assessment of older people at risk of falls without referral or direct intervention is not recommended Assessment of high risk residents in nursing homes with relevant referral is effective Evidence from well designed single trials shows that assessment and modification of risk factors of older people who have presented to an accident and emergency department after a fall and the provision of hip protectors in residents of nursing homes are effective Methods We updated two previous systematic reviews to include any new evidence up to March 1998. 4 5 We electronically searched Medline for all randomised controlled trials and systematic reviews by using the terms fall(s), accidental falls, fracture, elderly, aged, older, and senior. We followed up relevant references in papers, and we contacted researchers in prevention of falls for information about other trial evidence and about studies from journals not catalogued by the National Library of Medicine. For inclusion, studies had to be randomised controlled trials of interventions designed to minimise or prevent exposure to the risk factors for falling (or fracture) in people aged 65 years or over living in either community or residential care. Outcomes had to include the number of people who had fallen or the number of falls or fractures. We excluded drug or dietary treatments for the prevention of fractures. Trials that fulfilled the inclusion criteria were reviewed and summarised …
Article
Reports of cancer clinical trials often attempt to evaluate whether tumour response is associated with prolonged survival. Proper analysis requires accounting for the time-dependent nature of response status. We review a valid and relatively simple method of significance testing for this problem, and develop a corresponding non-parametric method for displaying the association between survival and occurrence of response. The new method applies to many other clinical problems involving representation and the association between survival and the occurrence of an event. We illustrate the method with data from two clinical trials.
Article
Several preventive strategies have proven effective at reducing the occurrence and rate of falling. It remains to be determined, however, whether, and to what extent, falls and/or fall injuries are independent determinants of adverse functional outcomes in older persons. A probability sample of 1,103 community-dwelling persons over age 71 years was followed for 3 years. The 957 cohort members (87%) who participated in at least one follow-up interview while residing in the community were included in this study. Outcome measures included one and three year change in basic and instrumental activities of daily living (BADLs-IADLs), social activities, and physical activities. Based on daily calendars and hospital surveillance, participants were placed into one of four levels of fall status: no falls, one fall without serious injury, at least two falls without serious injury, and one or more falls with serious injury. Hierarchical linear regression models, sequentially adding six domains of covariates, were constructed to examine fall status as a risk factor for change in function. One noninjurious fall (beta = -.437; p < .01), at least two noninjurious falls (beta = -.877; p < .001); and at least one injurious fall (beta = -1.254; p < .001) were each associated with decline in BADL-IADL function over 3 years after adjusting for covariates (model R2 = .2617). Experiencing two or more noninjurious falls (beta = -.538; p < .05) was associated with decline in social activities (model R2 = .2779) while experiencing at least one injurious fall (beta = -.580; p < .01) was associated with decline in physical activity (model R2 = .4231). Falls and fall injuries appear to be independent determinants of functional decline in community-dwelling older persons. Falling is a health condition meeting all criteria for prevention: high frequency, evidence of preventability, and high burden of morbidity.
Article
Identification of different types of falls and fallers among elderly persons might aid in the targeting of preventive efforts. In a representative sample of 336 community elderly, subjects were assigned to Frail, Vigorous, or Transition groups based on observed patterns of clustering among demographic, physical, and psychological variables. The frequency and circumstances of falls in these three groups were then ascertained. As expected, the observed incidence of falling in one year of follow-up was highest in the Frail group (52%) and lowest in the Vigorous group (17%). However, 22% (5/23) of falls by vigorous subjects, but only 6% (5/89) of falls by frail subjects, resulted in a serious injury. Compared with frail subjects, vigorous fallers were somewhat more likely to fall during displacing activity (53% vs 31%), with an environmental hazard present (53% vs 29%), and on stairs (27% vs 6%). These findings suggest that fall-related injuries can be a serious health problem for vigorous as well as frail elderly persons. Injury prevention, therefore, should be directed at all elderly persons but tailored to expected differences in fall circumstances.
Article
A sample of 761 subjects 70 years and over was drawn from general-practice records of a rural township. Each subject was assessed and followed for 1 year to determine the incidence of and factors related to falls. The fall rate (number of falls per 100 person-years) increased from 47 for those aged 70-74 years to 121 for those 80 years and over. There was no sex difference in fall rate but men were more likely than women to fall outside and at greater levels of activity. Twenty per cent of falls were associated with trips and slips but we found no evidence that inspection of homes and installation of safety features would have decreased the fall rate. Ten per cent of falls resulted in significant injury. Men who fell had an increased subsequent risk of death compared with those who did not fall (relative risk 3.2, 95% CI 1.7-6.0). Subsequent mortality was increased among women who fell but not to significant levels (relative risk 1.6, 95% CI 0.9-2.7).
Article
Falls are a leading cause of death from injury among older persons in the United States, and about one in three older persons falls each year. Yet, reliable estimates of the incidence of fall injury events in a population-based setting are not readily available. Therefore, the authors analyzed population-based surveillance data, between July 1985 and June 1987, from the Study to Assess Falls Among the Elderly, Miami Beach, Florida. The rate of fall injury events coming to acute medical attention increased exponentially with age for both elderly men and women (predominantly white), reaching a high for those aged 85 years or more of 138.5 per 1,000 for males and 158.8 per 1,000 for females. Compared with males, females had a higher incidence of fractures other than skull. Males were nearly twice as likely to die, however, following a fall injury event than were females. Of those fall injury events identified through the surveillance system, about 42% resulted in hospital admission. The mean length of hospital stay was 11.6 days overall and was 15.5 days for hip fracture, 9.8 days for skull fracture/intracranial injury, 11.2 days for all other fractures, and 9.1 days for all other injuries. About 50% of fall injury events that occurred at home and required hospital admission resulted in a person being discharged to a nursing home.
Article
This article has no abstract; the first 100 words appear below. THE annual incidence of falls among elderly persons living in the community increases from 25 percent at 70 years of age to 35 percent after 75 years of age.¹ Fifty percent of elderly persons who fall do so repeatedly. Falls are even more common in nursing homes, where the average annual incidence of reported falls is 1600 per 1000 patients.² Women fall more often than men until the age of 75 years, after which the frequency is similar in both sexes.¹ In the statistics reported here, and in the field of geriatrics generally, "falls" excludes those that result from major . . . Dr. Tinetti is the recipient of an academic award (K08AG00292) from the National Institute on Aging. Source Information From the Department of Medicine (M.E.T.) and the Department of Epidemiology and Public Health (M.S.), Yale University School of Medicine, New Haven, Conn. Address reprint requests to Dr. Tinetti at the Department of Medicine, Yale University School of Medicine, 333 Cedar St., P.O. Box 3333, New Haven, CT 06510–8056.
Article
We investigated factors associated with falls in a community-based prospective study of 761 subjects 70 years and older. The group experienced 507 falls during the year of monitoring. On entry to the study a number of variables had been assessed in each subject. Variables associated with an increased risk of falling differed in men and women. In men, decreased levels of physical activity, stroke, arthritis of the knees, impairment of gait, and increased body sway were associated with an increased risk of falls. In women, the total number of drugs, psychotropic drugs and drugs liable to cause postural hypotension, standing systolic blood pressure of less than 110 mmHg, and evidence of muscle weakness were also associated with an increased risk of falling. Most falls in elderly people are associated with multiple risk factors, many of which are potentially remediable. The possible implications of this in diagnosis and prevention are discussed.
Article
To study risk factors for falling, we conducted a one-year prospective investigation, using a sample of 336 persons at least 75 years of age who were living in the community. All subjects underwent detailed clinical evaluation, including standardized measures of mental status, strength, reflexes, balance, and gait; in addition, we inspected their homes for environmental hazards. Falls and their circumstances were identified during bimonthly telephone calls. During one year of follow-up, 108 subjects (32 percent) fell at least once; 24 percent of those who fell had serious injuries and 6 percent had fractures. Predisposing factors for falls were identified in linear-logistic models. The adjusted odds ratio for sedative use was 28.3; for cognitive impairment, 5.0; for disability of the lower extremities, 3.8; for palmomental reflex, 3.0; for abnormalities of balance and gait, 1.9; and for foot problems, 1.8; the lower bounds of the 95 percent confidence intervals were 1 or more for all variables. The risk of falling increased linearly with the number of risk factors, from 8 percent with none to 78 percent with four or more risk factors (P less than 0.0001). About 10 percent of the falls occurred during acute illness, 5 percent during hazardous activity, and 44 percent in the presence of environmental hazards. We conclude that falls among older persons living in the community are common and that a simple clinical assessment can identify the elderly persons who are at the greatest risk of falling.
Article
The objective of this study was to develop a prospectively applicable method for classifying comorbid conditions which might alter the risk of mortality for use in longitudinal studies. A weighted index that takes into account the number and the seriousness of comorbid disease was developed in a cohort of 559 medical patients. The 1-yr mortality rates for the different scores were: "0", 12% (181); "1-2", 26% (225); "3-4", 52% (71); and "greater than or equal to 5", 85% (82). The index was tested for its ability to predict risk of death from comorbid disease in the second cohort of 685 patients during a 10-yr follow-up. The percent of patients who died of comorbid disease for the different scores were: "0", 8% (588); "1", 25% (54); "2", 48% (25); "greater than or equal to 3", 59% (18). With each increased level of the comorbidity index, there were stepwise increases in the cumulative mortality attributable to comorbid disease (log rank chi 2 = 165; p less than 0.0001). In this longer follow-up, age was also a predictor of mortality (p less than 0.001). The new index performed similarly to a previous system devised by Kaplan and Feinstein. The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death from comorbid disease for use in longitudinal studies. Further work in larger populations is still required to refine the approach because the number of patients with any given condition in this study was relatively small.
Article
The prevention of disability in elderly people poses a challenge for health care and social services. We conducted a three-year, randomized, controlled trial of the effect of annual in-home comprehensive geriatric assessment and follow-up for people living in the community who were 75 years of age or older. The 215 people in the intervention group were seen at home by gerontologic nurse practitioners who, in collaboration with geriatricians, evaluated problems and risk factors for disability, gave specific recommendations, and provided health education. The 199 people in the control group received their regular medical care. The main outcome measures were the prevention of disability, defined as the need for assistance in performing the basic activities of daily living (bathing, dressing, feeding, grooming, transferring from bed to chair, and moving around inside the house) or the instrumental activities of daily living (e.g., cooking, handling finances and medication, housekeeping, and shopping), and the prevention of nursing home admissions. At three years, 20 people in the intervention group (12 percent of 170 surviving participants) and 32 in the control group (22 percent of 147 surviving participants) required assistance in performing the basic activities of daily living (adjusted odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.8; P = 0.02). The number of persons who were dependent on assistance in performing the instrumental activities of daily living but not the basic activities did not differ significantly between the two groups. Nine people in the intervention group (4 percent) and 20 in the control group (10 percent) were permanently admitted to nursing homes (P = 0.02). Acute care hospital admissions and short-term nursing home admissions did not differ significantly between the two groups. In the second and third years of the study, there were significantly more visits to physicians among the participants in the intervention group than among those in the control group (mean number of visits per month, 1.41 in year 2 and 1.27 in year 3 in the intervention group, as compared with 1.11 and 0.92 visits, respectively, in the control group; P = 0.007 and P = 0.001, respectively). The cost of the intervention for each year of disability-free life gained was about $46,000. A program of in-home comprehensive geriatric assessments can delay the development of disability and reduce permanent nursing home stays among elderly people living at home.
Article
The European Dialysis and Transplantation Association-European Renal Association (EDTA-ERA) Registry, now some 30 years old, has collected data throughout Europe since its inception and now covers nearly 700 million people in some 36 countries. Approximately 2,000 centers report to it. It has been possible to follow the way in which treatment for renal failure has developed in Europe, and this has not always been uniform. The nature of the treatment offered, the survival of patients on treatment, and sequentially many areas of their management have been addressed and reported. The Registry continues to work both in the field of end-stage renal failure and other fields of renal disease. It is assisting in the development of national registries and subnational renal registries throughout Europe. The multinational, multicultural nature of its area of interests makes this Registry a uniquely placed source to study many aspects of the management of patients with renal disease and of contributing to their care in the variety of healthcare system that exist in Europe and in the countries bordering the Mediterranean.
Article
There were 7,059 (403 per million) Australian patients and 1,341 (388 per million) New Zealand patients receiving renal replacement treatment at the end of 1992. Fifty-three percent and 50%, respectively, were dependent on a functioning transplant, 87% and 80%, respectively, from a cadaver donor. In Australia the majority of dialysis patients depended on hemodialysis (68%) and continuous ambulatory peritoneal dialysis (CAPD) (31%); 68% of patients were dialysing at home or in a satellite (free-standing) facility. The majority (62%) of home dialysis patients used CAPD treatment. In New Zealand there were 44% of patients on hemodialysis; 83% dialyzed at home and the majority (65%) used CAPD treatment. Few dialysis units (five of 71) in Australia were "for-profit" facilities; there was none in New Zealand. Universal health care has been available for renal replacement treatment for 20 years. The annual incidence of new patients increased steadily during the past 10 years, to 61 per million (Australia) and 69 per million (New Zealand) in 1992. There were disproportionate numbers of indigenous Australian Aboriginals (51%), New Zealand Maoris (30%), and Polynesian Pacific Islanders (11%) compared with their distribution in the general population. There was a considerable increase in elderly and diabetic patients during the period from 1983 to 1992: in Australia, 25% of patients were over 65 years of age and 14% of patients were diabetic, and in New Zealand, 16% of patients were over 65 years of age and 25% of patients were diabetic. The renal transplantation rate has remained unchanged since 1983 at 27 per million in Australia, but has increased markedly from 20 to 33 per million in New Zealand. The annual transplantation rate was 20% to 30% of those patients aged 15 to 64 years who were likely to be transplanted. The multifactorial analysis of risk factors for survival of dialysis patients showed age, male gender, CAPD treatment, Aboriginal race, and diabetic or analgesic nephropathy to be associated with lower rates of survival. Deaths were commonly due to a cardiac cause (43%), mostly myocardial infarction, or to infection (17%) or withdrawal from treatment (14%). The overall death rate was 12% of patients at risk in 1992. Multifactorial analysis of risk factors for graft survival in transplanted patients showed patient age, diabetic nephropathy, donor age, single-drug regimen, and low transplant activity (operations) at a center to be associated with lower rates of survival.(ABSTRACT TRUNCATED AT 400 WORDS)
Article
The eight FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques) sites test different intervention strategies in selected target groups of older adults. To compare the relative potential of these interventions to reduce frailty and fall-related injuries, all sites share certain descriptive (risk-adjustment) measures and outcome measures. This article describes the shared measures, which are referred to as the FICSIT Common Data Base (CDB). The description is divided into four sections according to the four FICSIT committees responsible for the CDB: (1) psychosocial health and demographic measures; (2) physical health measures; (3) fall-related measures; and (4) cost and cost-effectiveness measures. Because the structure of the FICSIT trial is unusual, the CDB should expedite secondary analyses of various research questions dealing with frailty and falls.
Article
Injuries and violence are major causes of disability and death among adults aged > or =65 years in the United States. Injuries impair older adults' quality of life and result in billions of dollars in health-care expenditures each year. This report reviews 1987-1996 data regarding fall-related deaths, 1988-1996 data on hospitalizations for hip fracture, 1990-1997 data regarding motor vehicle-related injuries, 1990-1996 data on suicides, and 1987-1996 data on homicides. Data on fall-related deaths, suicides, and homicides are from the National Center for Health Statistics annual mortality data tapes for 1987-1996. Homicide data are supplemented with information from the Federal Bureau of Investigation's Supplemental Homicide Reports for 1987-1996. Data on hospitalizations for hip fracture are from the 1988-1996 National Hospital Discharge Surveys. Information regarding motor vehicle-related injuries for 1990-1997 is from the National Highway Traffic Safety Administration's Fatality Analysis Reporting System and General Estimates System. Rates of fall-related deaths for older adults increased sharply with advancing age and were consistently higher among men in all age categories. Men were 22% more likely than women to sustain fatal falls. A trend of increasing rates of fall-related deaths was observed from 1987 through 1996 in the United States, although rates were consistently lower for women throughout this period. Rates of hospitalizations for hip fracture differed by age and were higher for white women than for other groups. Rates increased with advancing age for both sexes but were consistently higher for women in all age categories. U.S. hospitalization rates for hip fracture increased for women from 1988 through 1996 while the rates for men remained stable. Rates of motor vehicle-related injuries increased slightly from 1990 through 1997, and marked variations in state-specific death rates were observed; in most states, older men had death rates approximately twice those for older women. Although suicide rates remain higher among older adults than among any other age group, rates of suicide among adults aged > or =65 years decreased 16% during the study period. Suicide rates among older adults varied by sex and age group. Homicide rates declined 36% among older adults. Homicide rates were highest for black men, followed by black women and white men; the homicide risk for blacks relative to whites decreased from 4.8 to 3.9 per 100,000 persons, indicating that the gap between rates for blacks and whites is closing. Half of the older homicide victims were killed by someone they knew. The increase in rates of fall-related deaths and hip fracture hospitalizations from 1988 through 1996 might reflect a change in the proportion of adults aged > or =85 years compared with those aged 65-84 years - a change that results, in part, from reduced mortality from cardiovascular and other chronic diseases. Fall-related death rates might be higher among older men because they often have a higher prevalence of comorbid conditions than women of similar age. Racial differences in hospitalization rates might have some underlying biologic basis; the prevalence of osteoporosis, a condition that contributes to reduced bone mass and increased bone fragility, is greatest among older white women. Compared with whites aged > or =65 years, blacks of comparable ages have greater bone mass and are less likely to sustain fall-related hip fractures. Additional studies are needed to determine why rates of motor vehicle-related injury have increased slightly among older adults and why these rates vary by state. Declining rates of suicide among older adults might be related to changes in the effect or type of risk factors traditionally observed in this age group. Research is needed to identify reasons for variations in suicide rates among older persons. Homicides among olde
Article
Falls among elderly individuals occur frequently, increase with age, and lead to substantial morbidity and mortality. The role of vitamin D in preventing falls among elderly people has not been well established. To assess the effectiveness of vitamin D in preventing an older person from falling. MEDLINE and the Cochrane Controlled Trials Register from January 1960 to February 2004, EMBASE from January 1991 to February 2004, clinical experts, bibliographies, and abstracts. Search terms included trial terms: randomized-controlled trial or controlled-clinical trial or random-allocation or double-blind method, or single-blind method or uncontrolled-trials with vitamin D terms: cholecalciferol or hydroxycholecalciferols or calcifediol or dihydroxycholecalciferols or calcitriol or vitamin D/aa[analogs & derivates] or ergocalciferol or vitamin D/bl[blood]; and with accidental falls or falls, and humans. We included only double-blind randomized, controlled trials (RCTs) of vitamin D in elderly populations (mean age, 60 years) that examined falls resulting from low trauma for which the method of fall ascertainment and definition of falls were defined explicitly. Studies including patients in unstable health states were excluded. Five of 38 identified studies were included in the primary analysis and 5 other studies were included in a sensitivity analysis. Independent extraction by 3 authors using predefined data fields including study quality indicators. Based on 5 RCTs involving 1237 participants, vitamin D reduced the corrected odds ratio (OR) of falling by 22% (corrected OR, 0.78; 95% confidence interval [CI], 0.64-0.92) compared with patients receiving calcium or placebo. From the pooled risk difference, the number needed to treat (NNT) was 15 (95% CI, 8-53), or equivalently 15 patients would need to be treated with vitamin D to prevent 1 person from falling. The inclusion of 5 additional studies, involving 10 001 participants, in a sensitivity analysis resulted in a smaller but still significant effect size (corrected RR, 0.87; 95% CI, 0.80-0.96). Subgroup analyses suggested that the effect size was independent of calcium supplementation, type of vitamin D, duration of therapy, and sex, but reduced sample sizes made the results statistically nonsignificant for calcium supplementation, cholecalciferol, and among men. Vitamin D supplementation appears to reduce the risk of falls among ambulatory or institutionalized older individuals with stable health by more than 20%. Further studies examining the effect of alternative types of vitamin D and their doses, the role of calcium supplementation, and effects in men should be considered.