Speaker gives tips to assess, solve ‘geriatric problems’ among patients with CKD
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BOSTON — “Geriatric problems” can lead to adverse events among older patients with chronic kidney disease, but these can be identified and solved with assessments specific to this group, according to a speaker here.
“Geriatric problems appear more common as CKD progresses,” Rasheeda K. Hall, MD, MBA, MHS, an assistant professor of medicine in the division of nephrology at Duke University School of Medicine, said in a presentation at the National Kidney Foundation Spring Clinical Meetings. “Similarly, the burden of geriatric problems seems greater in older adults with renal failure than in those without. Compared to patients without kidney failure, older adults receiving dialysis have a greater proportion of falls per year, severe cognitive impairment, frailty, as well as polypharmacy.”
Not all who experience “geriatric problems” are older patients. Hall referenced a study that revealed 35% of patients on dialysis who were younger than 65 years old experienced frailty. Problems such as frailty can negatively impact CKD management and shared decision-making. Therefore, Hall recommends physicians assess patients for geriatric problems using the five M’s.
Five M’s
According to Hall, the five M’s of geriatric assessment are as follows: what matters most, mind, mobility, medications and multi-complexity.
Mobility can be measured with gait speed and functionality. If patients show signs of limited mobility, physicians might consider less intensive blood pressure management, measure mineral metabolism labs, minimize fall risk and order assistive devices or physical therapy. Similarly, if patients have limited mobility, it is likely they also show signs of limited functionality.
Cognitive impairment can be evaluated using the “mini-cog” tool. The tool consists of a three-item recall test and a clock draw. This evaluation should take around 3 minutes, Hall said. If the test yields abnormal results, physicians might consider home assistance or additional testing for the patient.
Optimizing medication adherence among patients experiencing geriatric problems can be achieved by simplifying the medication regimen, stopping medications that are no longer indicated or ordering home assistance.
According to Hall, “what matters most” refers to identifying a patient’s goals and care preferences, which is important for clinical decision-making for kidney replacement therapy. Physicians might determine this by asking patients to rank the following phrases in order of importance to them: maintaining independence; reducing or eliminating pain; keeping alive; or reducing or eliminating dizziness, fatigue and shortness of breath. This measurement can help physicians discuss goals of care with patients. Then, physicians can seek assistance from social workers or legal representatives if necessary.
Accounting for multi-complexity can be done by determining if a patient prioritizes one condition vs. another. Similarly, physicians might measure a patient’s social support and refer the patient for support services if needed.
“As we know, there are many things to do at a CKD clinic or doing rounds in a dialysis unit, so evaluating the five M’s can be incorporated into practice, but it does not have to be at every single visit,” Hall said.
The assessment can be done in triage, with intake forms or having patients answer one-on-one questions with personnel during multiple visits. Based on the results of the assessment, the suggested solutions listed above can be implemented for patients.
Inappropriate prescribing
Polypharmacy occurs when a patient is prescribed five or more medications and occurs often among patients with CKD. According to Hall, increased medications often lead to medication-related problems and can create a domino effect of hospitalizations and mortality. Additionally, polypharmacy can negatively affect patients’ quality of life and increase pill burden.
Among older adults, potentially inappropriate medications, such as sedatives, opioids and muscle relaxants, can impact a patient’s mind and mobility. Hall suggested that in some instances, physicians may “de-prescribe” medications by stopping or reducing a patient’s medication. Patients who should be prioritized for de-prescribing medications are those who have experienced a recent health status change, limited life expectancy, cognitive impairment or falls. Once the deprescribing process is complete, physicians might consider a medication alternative if needed.
“In summary, geriatric problems in older adults with kidney disease are common and impact both self-management and prognosis. The geriatric five M’s can be used to conduct geriatric assessment in older adults with kidney disease,” Hall said in the presentation. “Finally, de-prescribing is critical for managing polypharmacy and inappropriate prescribing in older adults with kidney disease.”
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Hall RK. Comprehensive approach to managing the elderly patient with advanced CKD/ESKD. Presented at: National Kidney Foundation Spring Clinical Meetings; April 5-10, 2022; Boston.
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