Dementia and cognitive impairment in ESRD: diagnostic and therapeutic strategies

Abstract

Cognitive impairment, including dementia, is a common but poorly recognized problem among patients with end-stage renal disease (ESRD), affecting 16-38% of patients. Dementia is associated with high risks of death, dialysis withdrawal, hospitalization, and disability among patients with ESRD; thus, recognizing and effectively managing cognitive impairment may improve clinical care. Dementia screening strategies should take into account patient factors, the time available, the timing of assessments relative to dialysis treatments, and the implications of a positive screen for subsequent management (for example, transplantation). Additional diagnostic testing in patients with cognitive impairment, including neuroimaging, is largely based on the clinical evaluation. There is limited data on the efficacy and safety of pharmacotherapy for dementia in the setting of ESRD; therefore, decisions about the use of these medications should be individualized. Management of behavioral symptoms, evaluation of patient safety, and advance care planning are important components of dementia management. Prevention strategies targeting vascular risk factor modification, and physical and cognitive activity have shown promise in the general population and may be reasonably extrapolated to the ESRD population. Modification of ESRD-associated factors such as anemia and dialysis dose or frequency require further study before they can be recommended for treatment or prevention of cognitive impairment.

Figure 1. Prevalence of cognitive impairment among patients with end-stage renal disease (ESRD) by age group

Note: The clinical trial sample consisted of 383 hemodialysis patients participating in the Frequent Hemodialysis Network Trials. Cognitive impairment was defined as a Modified Mini-Mental State Exam score <80 (ref. 15). The community sample consisted of 374 hemodialysis patients in Minnesota. Cognitive impairment was defined according to performance on a neuropsychological battery.

Figure 2. Prevalence of cognitive impairment among 23 405 US adults, according to estimated glomerular filtration rate (GFR)

Data are adapted from Kurella Tamura et al.

Figure 3

Proposed mechanisms of dementia in end-stage renal disease (ESRD).