Impact of on functional loss in elderly chronic kidney disease patients undergoing hemodialysis.
The incidence of end stage renal disease in older persons has been
increasing progressively over the last 10 years. Improved survival rates
with renal replacement therapy are making this increased prevalence even
more pronounced. The usual risks of morbidity and requirements for
specialized care associated with older people increase dramatically when
they have chronic kidney disease (CKD).
It has been seen that the majority of patients in hemodialysis units are over the age of 60, and have significant co-morbidities. The relationship between older age, chronic disorders and functional dependence (FD) is well known. Accordingly, nursing care planning must be designed with this in mind. The aim of this study was to assess whether the comorbidity associated with CKD modifies FD in patients on hemodialysis. We undertook a prospective longitudinal cohort study of hemodialysis outpatients in Malaga, Spain, using the Barthel test to establish FD and the Charlson comorbidity index to quantify comorbidity. All health events were analyzed to select those study patients with incident comorbidity, understood as the appearance of a new disease that could modify the Charlson comorbidity index, and determine the change in FD. Multivariate linear regression showed that the best model for predicting functional loss was that which considered comorbidity adjusted for age, particularly when it occurred as a result of hospital admission, as it was shown to have an important predictive value for the onset of a decrease in functional dependency scores in patients with CKD.
Key words: older patient, functional dependence, dialysis, comorbidity
Aged patients (Health aspects)
Aged patients (Analysis)
Hemodialysis (Health aspects)
Kidney diseases (Diagnosis)
Kidney diseases (Complications and side effects)
Kidney diseases (Analysis)
Kidney diseases (Prognosis)
Mansilla Francisco, Juan Jose
De los Rios Cuenca, Francisco Diez
Azana, Sandra Cabrera
Torres, Joaquin Cortes
Lopez, M Jose Macias
Gonzalez Castillo, Jose Antonio
Ferreras Duarte, Juan Luis
|Publication:||Name: CANNT Journal Publisher: Canadian Association of Nephrology Nurses & Technologists Audience: Trade Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2012 Canadian Association of Nephrology Nurses & Technologists ISSN: 1498-5136|
|Issue:||Date: Jan-March, 2012 Source Volume: 22 Source Issue: 1|
|Geographic:||Geographic Scope: Spain Geographic Code: 4EUSP Spain|
Introduction and literature review
One of the consequences of the aging population in Spain is the high number of older patients with CKD who require renal replacement therapy with hemodialysis. Older patients (> 60 years of age) on dialysis frequently have additional comorbidities that compound their illness, the ability to be independent, and consequent care needs. Several studies have attempted to define the more important epidemiological factors affecting the use of resources, prognosis and workload (Lamping et al., 2000; Collins et al., 2009; Lorenzo et al., 2010). The relationship between older age, chronic disease and functional dependence (FD) has been demonstrated (Becker, 1994; WHO-ICF, 2001).
Indeed, the Spanish law 39/2006, the Personal Autonomy and Dependent Care Law (Ley 39/2006, 2006) clearly indicates the intention of the Spanish national health system to assist those who have lost autonomy and independence due to disability or age. Thus, nephrology nurses need to adapt care to the characteristics of these patients in accordance with the law. It is necessary to be aware of the prevalence of FD of patients in order to plan and provide nursing care to meet patients' needs, as well as manage workload and resources. The regional nursing care plans of the Health Ministry of the Andalusian Government, as well as its 2008 Program Contracts, specify that nurses should identify frail and fragile elderly patients--with special attention to those patients with multipathologic processes, as age by itself is not necessarily a definitive conditioning factor of dependence. Other studies have echoed the importance of these multipathological processes in older persons and their impact on health and health care (Medrano et al., 2007; Carlos et al., 2009).
Other studies have echoed the importance of these multipathological processes in older persons and their impact on health and health care (Medrano et al., 2007; Carlos et al., 2009). The Spanish Society of Nephrology Quality Group included the Charlson comorbidity index among the indicators of quality care in hemodialysis in 2003, thus recognizing the need for assessing comorbidities in planning quality care.
The mean prevalence of patients with CKD on replacement therapy according to the Spanish Registry of Renal Patients for 2009 is 1,039 cases per million inhabitants, with a mean incidence of 129 cases per million inhabitants, with close to 60% of those on renal replacement therapy being over the age of 60 (SEN, 2010). Thus, due to the advanced age of patients seen in dialysis units in Spain, nursing care planning should take this factor into account. In one article (Jassal et al., 2009) authors identified how important it is to assess frailty and function when older patients start dialysis.
We used the University of California, San Francisco, Symptom Management Model (UCSF-SMM) (Dodd et al. 2001), which considers the presence of a two-way relationship between the onset, perception and response to disease symptoms by the individual and their functional status and morbidity-comorbiditymortality. This relationship is expressed in the three domains of scientific nursing: person, health-illness and environment. These domains can be represented by a Euler-Peirce diagram with zones of intersection and mutual influence. Each variable in our study belongs to one of these three interrelated domains.
The study hypothesis was that incident comorbidity triggers functional loss. We undertook a prospective, observational, longitudinal cohort study of the 101 outpatients over the age of 60, who agreed to be studied, with no initial acute active diseases and who were on the outpatient hemodialysis program in June 2009. The observation period was 12 months.We evaluated all of the health-related incident events in the study group and the change in FD during the study period.
We chose the Barthel index to measure FD because of its ability to discriminate between the World Health Organization International Classification of Functioning, Disability and Health (WHO-ICF, 2001) categories in section 2, named "Activity Limitations and Participation Restriction". This test is one of the standards of care in nursing practice in hospitals of our National Health System, so it was easily recorded. The Barthel index is scored from 0-100, with cut-off points set at 20, 60 and 90 to define a FD scale. A lower score indicates a higher FD, thus: 0 to 20 points represents total dependency; 20 to 60: severe; 60 to 90: moderate and 90 to 99: mild dependency. Only a score of 100 indicates independence. Nurses can measure FD when they suspect that a patient's baseline is changed and always at their own discretion. Functional loss (FL) was defined as a difference of at least 10 points between two measurements of the Barthel index, before and after a particular event (Mahoney & Barthel, 1965).
For the purposes of this study, the event was defined as the appearance of a diagnosis of ongoing comorbidity. The Charlson Comorbidity Index (CCI) was used to measure this comorbidity (Charlson et al., 1987).
This index provides an overall score obtained by summing up partial scores depending on whether events are diagnosed during the natural history of the patient's disease. These partial scores are weighted according to the severity of the event. The comorbid conditions listed are diseases accompanying the main one (in this case CKD) and not considered an acute illness. This study was done using Beddhu's modification for nephrologic patients (Pittsburgh University) (Beddhu et al., 2000) (see Table 1). In order to stratify the sample we consider mild disorders those scoring 1 or 2 points on the CCI table, and severe those scoring 3 or 6 points.
The CCI can be adjusted for age by adding one point to the total score for each 10 years above the age of 40 years (CCIage) (Charlson et al., 1994). The CCI was used to measure the comorbidity alone, and the CCIage was used to analyze the impact of age on comorbidity. The cut-off points were analyzed in quartiles. A patient was considered to have an initial comorbidity value according to the diagnoses reported in the clinical history, as determined by chart review.
Incident comorbidity was considered to be that which modified the baseline CCI or CCIage.
Both the Barthel index and Charlson score are user-friendly tools, largely used by the scientific community, and are validated to Spanish language and contrasted for many purposes, including nephrology scope (Cid-Ruzafa, 1997; Camps et al., 2009; SEN, 2007). This study was approved by the bioethics committee of Malaga Regional Hospital and all participants signed an informed consent prior to being included in the study.
The independent variables considered were sex, age, initial FD (FDstart) (all of them belonging to the UCSF-SMM person domain), etiology of the CKD, hospital admission during the observation period, initial CCI (CCIstart) or CCI after an event (CCIend), death (UCSF-SMM health-disease domain), and time on dialysis (UCSF-SMM environment domain). The study variables were final FD (FDend) and functional loss (FL) (UCSF-SMM person domain).
Sociodemographic, medical, and treatment-related data were obtained from medical records and patient interviews. Comorbid conditions were determined through chart review of documentation by the nursing personnel of the dialysis unit. These conditions were verified through review of physician notes in the clinical history. Any queries related to the diagnosis of comorbidities were resolved during joint clinical review sessions.
We analyzed the correlation between age, modifications in the CCI and subsequent FD changes. Kaplan Meier and log rank survival curves were analyzed. Multivariate logistic regression was used with independent variables. Other statistical tests used included ANOVA for the FD score, [chi] 2 test, Wilcoxon and Mann Whitney U tests for non-parametric tests (mainly to study the interquartile ranges of the CCI score). The Kolmogorov-Smirnov Z test was used to determine non-normal distributions, the Student t test to compare the means of related samples (between comorbidity groups), and the odds ratio (OR) for the dichotomous model of independent variables generating the presence or not of functional loss. All calculations were made using SPSS v.15, under license from Malaga University, and EpiInfo 6.0 from the CDC in Atlanta.
Of the 101 patients who started the study, 81 (80.2%) completed the follow-up. The reasons for loss were: transplant (n = 6; 5.9%), transfer to another dialysis centre (n = 5; 4.9%) and death (n = 9; 8.9%). The sociodemographic characteristics of the cohort were (mean [+ or -] SD): age: 58.8 [+ or -] 18 years, time on hemodialysis: 89.2 [+ or -] 78.7 months (interquartile range: 34-132, median: 50) and sex: 56.8% male.
No significant association was found between sex, age or treatment time. The time during which patients were transplanted was excluded from the hemodialysis time in this study.
The etiology of CKD did not differ significantly from other prevalence studies in Spain (Portoles et al., 2007; Herrero et al., 2006) or Italy (Di Iorio et al., 2004): glomerulonephritis (22%), interstitial disorders (21%), vascular disorders (12%) and diabetes (13.6%).
The FDstart of the cohort was as follows: independent, 59.3%; mild dependence, 12.3%; moderate dependence, 7.4%; severe dependence, 16%; and total dependence, 4.9%. The overall changes in FD and the CCIage (44 patients experienced comorbid events) were: FDstart 83.2 [+ or -] 26.3 to FDend 78.2 [+ or -] 32.1 (mean [+ or -] SD) and CCIage-start five to CCIage-end six (median). Three patients had more than one episode that modified CCI. In these cases we analyzed changes in FD after last change in comorbidity, taking the sum of scores of several events in one step.
Analysis of the whole sample showed a significant bilateral correlation (P < 0.01) between age, CCI and FD with the Pearson (-0.4 for FD and 0.8 for the CCI) and the Spearman coefficients (-0.3 and 0.8, respectively). A bivariate correlation was also seen between comorbidity and dependence (Pearson: 0.4; Spearman: 0.5). These findings showed a strong relationship between the three variables taken two by two. The FDend was 93.7 [+ or -] 17.3 for the patients with a CCI below the median (P50) and 68.6 [+ or -] 35.4 for the group with a CCI above P50 (P < 0.01).
The distribution by sex showed a significant difference for the Barthel score at the end of the study. Overall, FD in the women worsened over the study period, but with no significant association with the proportional worsening on the CCI. This could be because, at the start of the study, the women were generally situated in the group with a CCI above P50 and, thus, started at a disadvantage (Table 2).
As the groups were dispersed when we stratified the sample according to the CCI percentiles, as in the study by Beddhu et al. (2000), we divided the sample into just two groups, above and below the median. The study group comprised the patients who experienced a change in their CCI, as they had diagnostic events that increased their comorbidity. Table 3 shows the median CCIend. The difference between the FDstart and FDend in the group with increased comorbidity (CCIage-end > CCIage-start) compared with the group that did not experience an increase was significant (Student t test for related samples, P < 0.01). That is, all increases in comorbidity resulted in an overall functional loss, a result that has been demonstrated elsewhere (Medrano et al., 2007). During the study period there were 22 admissions. To evaluate the influence of these admissions on the loss of functionality, the 22 admissions were divided between those that produced incident comorbidity (seven episodes: pulmonary thromboembolism with sequelae, solid tumour, COPD, congestive heart failure and three related to ulcers) and those that did not (15 others). A diagnosis of incident comorbidity made as a consequence of hospital admission was significantly associated with FL (x2: 20.7; P < 0.01).
As those patients who experienced a worsening in the CCI did not do so linearly, two groups were considered, according to the number of associated accompanying disorders, in order to assess the effect on FD of the onset of various adverse conditions: Group 1, with a difference in score (not attributable to age) of two or three points (two mild accompanying disorders); Group 2, with a difference of four or more points (at least one severe accompanying disorder). The decline in FD of these two groups is shown in Table 4.
At initial data interpretation, sex was not considered to be an independent variable, as originally thought, because it was contaminated by lower initial scores for FD and CCIage. In other words, in this cohort, women had poorer health status initially. Linear regression analyses showed that the model that best predicted the FDend was that which considered the FDstart group, initial comorbidity modified for age older than the median (CCIage-start > P50), a greater increase in the CCIage ([DELTA]CCIage) and having been admitted with a diagnostic comorbidity event with a corrected [r.sup.2] = 0.62 (P < 0.001), with no association with time on dialysis or CKD etiology. No model explained consistently the number of points lost between FDstart and FDend ([DELTA]FD) (Table 5).
Taking FL (at least 10 points between FDstart and FDend) as a dichotomous dependent variable, the independent variables with the greatest impact in the binary regression model were Admission with OR 3.1 (95% CI: 0.5-19) and [DELTA]CCIage with OR 1.6 (95% CI: 1.1-2.2).
The survival study -- taking into account mortality, stratified according to the P50 of the CCIend without modifying for age (3 cases with less comorbidity than the median and 6 cases with more comorbidity) -- was not significant (log Rank: 1.5. P = 0.2) (Figure 1).
The FD of patients is a known modifier of the workload of nursing teams and the instruments used for its measurement are user-friendly and provide a useful analysis of our patients' needs. The combination of an aging population and the sequelae of comorbidity (understood as new chronic disease) represent a great source of consumption of health care resources and workload (Lendinez et al., 2007; Medrano et al., 2007). This scenario also applies to nephrology and dialysis treatments (Beddhu et al., 2000). In this epidemiologic study we mapped the general characteristics of the dialysis population in our hospital, which were similar to other Western Europe results (Portoles et al., 2007; Herrero et al., 2006; Di Iorio et al., 2004).
With improvements in hemodialysis technology, patients are surviving longer and tend to be a more elderly population, lending to a higher burden of comorbidities. As direct care providers, nurses are in a unique position to assist with evidence-based assessments and planning that may assist in determining FD and associated resources that may be required in providing their care.
The population in our hospital-based outpatient dialysis program is composed mostly of patients older than 60 years of age, with varied causes of CKD, including cardiovascular disease and diabetes, and with a median time of four years undergoing renal replacement therapy. While there are external, ambulatory hemodialysis units in our area, they cater to a lower acuity population--and therefore the hospital-based dialysis unit cares for those patients with more significant health problems. In light of this, this study has assisted us in designing the overall nursing care delivered in dialysis units, recognizing that ancillary needs for this population are just as important, if not more so, than the quality of the hemodialysis itself.
The CCI-age is a very simple and user-friendly tool to administer and has proved useful as a prognostic factor for survival, resource allocation, admission and early readmission (Collins et al., 2009; Medrano et al., 2007; Beddhu et al., 2000). For nursing care, the CCI can be used as a complement to the functional evaluation scales, e.g., Karnofsky, Katz or WHODAS 2. Using these tools, continuous evaluation by the nurse of the onset of new events or diagnoses can be used to predict future care requirements in one or more functional areas, even before they appear.
[FIGURE 1 OMITTED]
The limitations of this study include the lack of examination of other study variables such as nutritional status, efficacy of dialysis or the subjective perception of health, in relationship to the dependent variable of FD. Antoine et al., 2004, explain that psychological disorders such as depression are higher in dialyzed elderly patients. Marcen et al., 1997, shows how malnutrition increases risk of comorbidity. Although we consider that subjective perceptions of health or nutritional status represent different aspects of the health-illness dimension on the UCSF-SMM, and should be brought together with the wider variables affecting morbidity-comorbidity, this would require more detailed study.
Our study indicates that incident comorbidity triggers functional loss, especially when it occurs concurrently with an event that culminates in hospital admission. This is particularly true when patients have previously suffered some degree of FD and have any known comorbidity, especially in the older patient. This finding corroborates with others carried out in both nonnephrology (Boyd et al., 2008; Abizanda et al., 2007) and nephrology studies (Lo et al., 2008).
As a prognostic factor, our findings warn of the increased need for assistance with activities of daily living upon return to the hemodialysis unit for an older patient returning from a complex hospital admission. Frail, elderly persons just at the onset of decline could have differing needs as a result of FD. The identification of the onset of health problems that may predict future admission, e.g., cardiac ischemia that worsens during hemodialysis, or diabetes that is progressively more difficult to control, would allow nurses to begin planning for supportive care, falls prevention strategies, or other care supports.
In conclusion, this study contributes to nursing knowledge by identifying that attention to older patients who experience intercurrent illness, particularly with hospital admission, is important, as this has been demonstrated to be a trigger for functional decline. Therefore, nurses should develop care plans that include supports following hospital admission such as increased monitoring, assistance for activities of daily living, and referrals for rehabilitation and additional homecare services.
Editors note: We are very pleased to be publishing this manuscript from our colleagues in Spain. When asked why they chose the CANNT Journal for their manuscript submission, they said the following: "I don't think that Canadian nurses realize the importance they hold for us; in Spain, the terms 'Canadian Nursing' and 'quality' are almost synonymous. We are proud to have been accepted to publish in the CANNT Journal."
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By Juan Jose Mansilla Francisco, RN, Francisco Diez De los Rios Cuenca, RN, Sandra Cabrera Azana, RN, Joaquin Cortes Torres, RN, Ma Jose Macias Lopez, RN, Jose Antonio Gonzalez Castillo, RN, and Juan Luis Ferreras Duarte, RN
Juan Jose Mansilla Francisco, RN, Transplant Coordinator, Malaga (Spain) Organ Procurement Service, Associate Professor of School of Health Sciences, Nursing Faculty Malaga University, Malaga, Spain.
Francisco Diez De los Rios Cuenca, RN, Nephrology Service, Regional University Hospital "Carlos Haya", Malaga, Spain.
Sandra Cabrera Azana, RN, Nephrology Service, Regional University Hospital "Carlos Haya", Malaga, Spain.
Joaquin Cortes Torres, RN, Nephrology Service, Regional University Hospital "Carlos Haya", Malaga, Spain.
Ma Jose Macias Lopez, RN, Nephrology Service, Regional University Hospital "Carlos Haya", Malaga, Spain.
Jose Antonio Gonzalez Castillo, RN, Nephrology Service, Regional University Hospital "Carlos Haya", Malaga, Associate Professor of School of Health Sciences, Nursing Faculty Malaga University, Malaga, Spain.
Juan Luis Ferreras Duarte, RN, Nephrology Service, Regional University Hospital "Carlos Haya", Malaga, Associate Professor of School of Health Sciences, Nursing Faculty Malaga University, Malaga, Spain.
Address correspondence to: Juan Jose Mansilla Francisco, RN, Regional University Hospital "Carlos Haya", Coordinacion de Trasplantes, Plaza Doctor Gutierrez Calzada, s/n 29010, Malaga SPAIN. Fax: +0034951291441. Email:
Submitted for publication: May 31, 2011.
Accepted for publication in revised form: January 29, 2012.
Table 1. Charlson Comorbidity Index modified by Beddhu Coronary artery disease(1) 1 Congestive heart failure Peripheral vascular disease(2) Cerebrovascular disease(3) Dementia(4) Chronic pulmonary disease Connective tissue disorder(5) Peptic ulcer disease(6) Mild liver disease(7) Diabetes(8) Hemiplegia 2 Moderate or severe renal disease Diabetes with end-organ damage Any tumour, leukaemia, lymphoma(9) Moderate or severe liver disease(10) 3 Metastatic solid tumour 6 AIDS (1.) included AMI (2.) Including intermittent claudication, aortic aneurysm, non-cardiac bypass surgery (3.) includes TIAs (4.) Or any chronic cognitive impairment (5.) Lupus, vasculitis, chronic and disabling rheumatic disease, polymyositis ... (6.) Any chronic digestive disease with evidence of active bleeding upper or lower (7.) Any type of hepatitis without systemic involvement (8.) with pharmacologic treatment (9.) no evidence of metastasis (10.) Cirrhosis of any etiology
Table 2. Distribution of sample by sex, CCIstart and CCIend above or below median CCIage-start CCIage-start OR CCIage-end CCIage-end > P50 > P50 (95% > P50 > P50 CI) Men n 23 23 2.89 20 26 = 46 (1.01; Women 9 26 8.41) 11 24 n= 35 OR (95% CI) Men n 1.68 = 46 (0.61; Women 4.68) n= 35 - CCIage-start vs P50: Initial CCI modified by age below or above median. - CCIage-end vs P50: Final CCI modified by age below or above median
Table 3. Relationship between age, FDend and CCI above or below median < P50 CCIend * > P50 X2 ANOVA (mean[+ or -]SD) CCIend * (mean[+ or -]SD) n 50 31 Age 43 [+ or -]12.6 68.5[+ or < 0.01 -]13.4 FDend 93.7[+ or -]17.3 68.6[+ or < 0.01 -]35.4 Sex (Female) 11 24 1.4 NS; P = 0.22 * CCI calculated without adding points for decade of age passed
Table 4. Evolution of FD between groups by mild or severe co-morbid events FDstart FDend (mean[+ or Mean AFD (mean[+ Wilcoxon * (mean[+ or -]SD) or -]SD) -]SD) Group 1 72.8 [+ or 57.1 [+ or 15.7[+ or P < 0.01 n=l4 -]37.6 -]36.8 -]20.2 Group 2 81.8 [+ or 64.3 [+ or 17.5 [+ or P < 0.01 n = 8 -]31.3 -]42.3 -]37.3 * Kolmogorov-Smirnov Z: P<0.01
Table 5. Regression model of significant independent variables and associated weight Variable Standardized coefficient P Group FDstart 0.68 <0.01 ACCIage 0.23 <0.01 CCIage-start > P50 0.16 <0.05 Admission 0.14 <0.05 - Group FDstart: independent, mild dependence, moderate dependence, severe dependence and total dependence. - [DELTA]CCIage: comorbidity increase (modified by age) - CCIage-start > P50: higher comorbidity than median at the beginning of the study
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