Considerations in starting a Patient with
Advanced Frailty on Dialysis: Complex Biology
meets challenging ethics. Clin J Am Soc Neprol.
2013 Jul;8(8):1421-8. Swindler M.
Jenni Harrison CT2
August 2013
Overview
• Frailty…….& Me
• The paper – technical aspects & background
• 3 issues to discuss:
– Effects of frailty
– ‘Renal Frailty Phenotype’
– Ethical aspects of renal care in an ageing
population
• My ‘extra slide’
• Conclusions & Discussion
Image source: Google images
Frailty
• What is frailty………?
Frailty
………a selection of Google Definitions:
(a) 2001 Psychological Thriller starring Matthew McConaughey
(b) physical or moral weakness
(c) the quality or state of being frail
(d) the state of being weak
in health or body (especially from
old age)
Alternatively, a term which is becoming
increasingly common, especially from
Geriatricians
Image source: Google images
Frailty & Geriatric Medicine
• Two broad schools of thought:
– Fried, Cardiovascular Health Study
• 3 or more of: unintentional weight loss, self-reported
exhaustion, weakness, slow walking speed, low physical
activity levels
• Predominantly a research tool
Frailty & Geriatric Medicine
• Two broad schools of thought:
– Fried, Cardiovascular Health Study
• 3 or more of: unintentional weight loss, self-reported
exhaustion, weakness, slow walking speed, low physical
activity levels
• Predominantly a research tool
– Rockwood, Frailty Index
• State of vulnerability that arises in relation to the
accumulation of health deficits
• Requires rating of at least 30 health states
• Difficult to apply in practice
Frailty & Geriatric Medicine
• Distinct from ‘ageing’ & ‘comorbidity’
• Remains an area of hot debate
• A recognised concept of value, but still a question
of how it is defined
– Many believe we ‘just know’ who is frail
– When scales are used, their role in decisionmaking/predicting outcomes is questioned (Wou et al.
2013)
– Scales/scores not used routinely in practice
– ‘Difficult to operationalise’
……& Me
A time to confess my conflicts of interest
• Trainee geriatrician
• Special interest in dementia and advanced
care planning
• New to your department
Single author, Mark Swindler
New York
Review article
2013
Image source: Google images
Background
• ‘Explosion’ in >80yr-olds with co-morbidities
and geriatric syndromes (inc frailty)
Background
• ‘Explosion’ in >80yr-olds with co-morbidities
and geriatric syndromes (inc frailty)
• Dialysis ‘routine practice in the current
environment of procedure-driven medical care
and biomedicalisation of aging’
Background
• ‘Explosion’ in >80yr-olds with co-morbidities and
geriatric syndromes (inc frailty)
• Dialysis ‘routine practice in the current
environment of procedure-driven medical care
and biomedicalisation of aging’
• Growing group with no absolute contraindications
for RRT, but are at risk for early mortality,
increased hospitalisation, acceleration of geriatric
syndromes and significant symptom burden
Background
• ‘Explosion’ in >80yr-olds with co-morbidities and
geriatric syndromes (inc frailty)
• Dialysis ‘routine practice in the current
environment of procedure-driven medical care
and biomedicalisation of aging’
• Growing group with no absolute contraindications
for RRT, but are at risk for early mortality,
increased hospitalisation, acceleration of geriatric
syndromes and significant symptom burden
• ‘…..patients and families are struggling with saying
no to dialysis therapy”
The effects of frailty – the WHAT
• The case is forwarded that:
– Dialysis patients (compared to cancer & HF)
•
•
•
•
More hospitalisations
More ICU admissions
More hospital deaths (less hospice use)
29% had at least 1 ‘life-sustaining’ interventions
(mechanical ventilations, CPR, feeding tube insertion)
The effects of frailty – the WHAT
• The case is forwarded that:
– Dialysis patients (compared to cancer & HF)
•
•
•
•
More hospitalisations
More ICU admissions
More hospital deaths (less hospice use)
29% had at least 1 ‘life-sustaining’ interventions (mechanical
ventilations, CPR, feeding tube insertion)
– 1st year mortality dialysis patients >80 yrs up to 46%
– In Nursing Home patients mortality rose, up to 58%
The effects of frailty – the WHAT
• The prevalence of frailty in the CKD population is
~2x of general geriatric OP community
• Frailty assoc. with starting dialysis at a higher
eGFR as well as increased mortality (attenuated
when correcting for frailty)
– Suggested due to ‘overlap with signs of uraemia’
• Frailty is ‘under-diagnosed’ because of the lack of
uniform definition and diagnostic criteria
Life expectancy Frail vs. Healthy
The ‘renal frailty phenotype’ – the WHO
‘Cycle of Frailty’ – trigger entry points
Frail renal phenotype
Ethical considerations – the WHY
• Complications
– Sudden death; cardiovascular events; recurrent and
prolonged hospitalisations; infections; need for longterm care; ICU admissions; chronic critical illness;
increasing frailty; functional decline; loss off
independence and dialysis discontinuation with
average survival of 8-10 days
– “There is no evidence that dialysis can reverse
geriatric syndromes like frailty, functional disability
and dementia”
Ethical considerations – the WHY
• Patient’s preferences for dialysis were
incorrectly predicted by
surrogates/family/doctors up to ONE THIRD
OF THE TIME
• Families consistently over-estimating patients’ desires
to continue dialysis
• CKD & Dialysis patients experience a
significant symptom burden ?inadequately
assessed, ?underuse of palliative care
Ethical considerations – the WHY
‘Extra Slide’
• Treat with caution ‘models’ to predict risk
– Inclusivity
• Referring back to ‘Frail Renal phenotype’
• Multitude of overlapping factors (age, disability,
risk of sudden death, dementia, comorbidities, NH
residence)
• Origins?
• How helpful is this really?
• …..vs clinical judgement, individualised
assessment?
‘Extra Slide’
• Treat with caution ‘models’ to predict risk
– Exclusivity
• An anecdote from Intercalated BSc (courtesy of
University of Glasgow)
– ABCD score TIA risk prediction
– Applied to clinic cohort
– …….BP not predictive factor for stroke/allcause mortality
– Depends on population used to derive the
score/scale
Other Relevant Guidance
• GMC Guidance (2010) Treatment and care
towards the end of life: good practice in
decision making http://www.gmcuk.org/guidance/ethical_guidance/end_of_life
_care.asp
(Supersedes the previous guidance “Withholding
and withdrawing life-prolonging treatments”)
References
• Fried LP, Tangen CM, Walston J, et al. Frailty in
older adults: evidence for a phenotype. J
Gerontol A Biol Med Sci. 2001;56(3):M146-56.
• Moorhouse P, Rockwood K. Frailty and its
quantitative clinical evaluation. J R Coll Physicians
Edin. 2012;42:333-40.
• Wou F, Gladman JR, Bradshaw L, et al. The
predictive properties of frailty-rating scales in the
acute medical unit. Age Ageing. 2013;May 10.
Epub ahead of print.
Conclusions & Discussion
• Frailty and Nephrology
– WHAT
– WHO
– WHY
• Potential pitfalls in screening tools
OVER TO YOU……….