Frailty And Dependence In Elderly Dialysis Patients

Patients older than 75 years of age currently represent more than 35% of the population that begins dialysis each year in most European registries; in our centre, at least 30 patients in this age bracket begin dialysis, which represent 45% of the total incident patients. The absence of systematic studies makes this patient category almost indistinguishable from other categories, even though its peculiarity is now becoming evident. At least 30-40% of elderly individuals are expected to be frail and/or dependent, but the incidence of frailty is likely to be higher in those undergoing haemodialysis. Due to severe physical and/or mental impairment and often because of social hardship, these patients rarely experience clinical stability and are dependent on third parties for their survival. Early symptoms of frailty consist of weakness, anorexia, weight loss, muscular atrophy, reactive depression and cognitive deficits. Commonly, early signs and symptoms are underestimated until patients become dependent as defined by the presence of several pathological conditions, such as instability, immobility, iatrogenic drug reactions, intellectual impairment, and incontinence. The last phase of the condition is that of acute complications pathological fractures, pressure ulcers, delirium, infectious complications with multiple hospital admissions, which cause a significant reduction in patient survival. The care of these patients presents complex problems for welfare services, and has led to the re-organisation of in-patient and out-patient dialysis units. Repeated patient admissions to the hospital require a much greater use of facilities and staff compared to younger dialysis patients. Of 112 elderly patients consecutively admitted to our dialysis programme over a period of 10 years, we identified 35 dependent ( defined here as the need for continual assistance) patients ( 31.2%). Dependence proved to be the only clinical parameter associated with survival, while co-morbidity ( in particular cardiovascular disease that usually affects survival rates in younger age groups) did not seem to be discriminating risk factors in the elderly. Emerging data from larger studies will likely demonstrate that the elderly should be systematically monitored for frailty and dependence during dialysis, as is the case in exclusively geriatric fields. Many of the clinical problems of the dialysed elderly, such as sensory, mental, and functional impairment, are more the result of advanced age, pre-existent diseases, and social deprivation, rather than of uraemia and dialysis per se. Prevention, as well as a therapeutic approach specifically modelled on these conditions, could help to improve the prognosis of this patient category, which is becoming numerically predominant in dialysis units.