Tag: geriatric

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Geriatric nephrology hits the NEJM

The introduction references the following study and states that in 1999:
  • Nursing home residents represented 4% of the people starting dialysis
  • Nursing home residents represented 11% of the people initiating dialysis over the age of 70
  • First year mortality is 35% for patients older than 70
  • First year mortality is 50% for patients older than 78
The investigator used the USRDS and The Minimum Data Set, a database of nursing home residents that all Medicare and Medicaid certified nursing homes must participate contribute to. The study cohort consisted of people who were in the nursing home prior to starting dialysis. Patients were included if they had a functional status assessment prior to initiating dialysis. This resulted in a cohort of 3,702 residents.
Functional status was measured by grading the following skills on a scale from 0 (total independence) to 4 (dependence):
  1. eating
  2. dressing
  3. toileting
  4. maintaining personal hygiene
  5. walking
  6. getting up out of a chair
  7. moving around in bed
Increases in scores A second measure of functional status, MDS-ADL, was also used. Demographic, co-morbidity data was collected from the Form 2728 genereated by the nephrologist at the time of the initiation of dialysis.
200 patients were excluded from the analysis because they failed to have a funcrional status assessment prior to starting dialysis. These patients were healthier than the study cohort. I don’t feel this is a critical bias as this represented a rather small fraction of the cohort. My guess is the results of this study fairly represent the population of dialysis nursing home residents.

The key points are beautifully rendered in two charts. The first shows the mortality of the cohort following the initiation of dialysis:
The bars represent the timing of the ADL assessment. The dotted line is cummulative mortality. The red arrow is the half-life of this population. Half the cohort is dead before 9months!
Looking at the mortality alone one must wonder if the patients are receiving any survival benefit from dialysis. It is hard to imagine the mortality is much worse if they didn’t get dialyzed.
The meat of the article is in next graph that shows the distribution of functional status every 3 months. It goes back a year prior to initiating dialysis and follows forward for the first year after initiating dialysis. Patients demonstrate a stable functional status until the 3 months prior to starting dialysis. In the three months prior to initiation there is some subtle decreases in functional status but that really accelerates as soon as they start dialysis.
The combined end points of death and deterioration are shown in a bleak graph:

What a depressing study, both mortality and morbidity. It forces nephrologists to question the role of dialysis in nursing home residents. This is a population that does terrible on dialysis.
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PBFluids has been a little quiet recently

In the past few weeks I have been working on two presentations. The first was to Genzyme’s scientists and the second was grand rounds at Providence. I have been spending way too much time working on those two talks. Thankfully the bones of both talks were the same. I spoke on the problem of chronic kidney disease on the elderly, specifically whether CKD was over diagnosed (yes it is) in this population and can it be safely ignored (no it can’t).

I’m not completely through the gauntlet yet. I still have to provide a chapter on lifestyle modification for the control of blood pressure.

But I can’t describe the awesome feeling of relief from delivering the grand rounds this morning.

For those of you with iWork and Keynote here is the presentation:

The Two Faces of Geriatric CKD

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Is hypertension in octagenarians a characteristic or a disease

I was at the NKF Spring Clinical meeting and I saw variations of the two following slides in at least three different lectures:

The slide on the left comes from the AHA Heart Disease and Stroke Statistics from 2007 (PDF). It shows the increasing prevalence of hypertension as people get older. The slide on the right is from the Framingham Heart Study (PDF) and shows the 20 year risk for normotensive adults for developing hypertension. Both figures are repeated below:


The part of these figures that kept gnawing at my brain was putting them together, stacking them if you will. 60-70% of the sixty-year olds have hypertension and the minority that are normotensive have a 90% chance of developing hypertension by the time they are 85. So essentially every 80 year old has hypertension.

Does hypertension cease to be a disease when everybody has it? Is hypertension less pathology and rather part of the normal physiology of aging?

Speaking against the idea of geriatric hypertension being normal physiology is the powerful survival advantage gained by treating the high blood pressure. This data comes from HYVET published last spring in the NEJM (PDF). Prior to HYVET there was retrospective data pointing to better survival with higher blood pressures (Oates 2007) and a meta-analysis of 80+ year olds enrolled in RCTs showed a reduction in cardiovascular evens but a trend to increased total mortality.

The HYVET ransdomized 3,845 octagenarians with blood pressures 160-190 with a diastolic of less than 110 to either placebo or indapamide (thiazide-like diuretic) with additional perindopril if the systolic blood pressure remained over 150. The primary end-point was number of strokes (fatal + non-fatal)

Results. The investigators achieved good blood pressure separation between the control and experimental groups with a 15 mmHg difference in the systolics and 6 mmHg difference between the diastolics.

The effect on morbidity and mortality were dramatic (all results expressed as intension-to-treat) with active treament resulting in:

  • 30% reduction in the rate of fatal or nonfatal stroke (95% confidence interval [CI], –1 to 51; P=0.06)
  • 39% reduction in the rate of death from stroke (95% CI, 1 to 62; P=0.05)
  • 21% reduction in the rate of death from any cause (95% CI, 4 to 35; P=0.02)
  • 23% reduction in the rate of death from cardiovascular causes (95% CI, –1 to 40; P=0.06)
  • 64% reduction in the rate of heart failure (95% CI, 42 to 78; P<0.001)
  • Fewer serious adverse events (358, vs. 448 in the placebo group; P=0.001).
Click on the graphs to see larger versions.

So even if hypertension in the elderly is not a disease, treating it seems to have dramatic benefits for patients. Vote your opinion!