Phenotypes of Symptom, Function, and Medication Burden in Older Adults with Nondialysis Advanced Kidney Disease

Abstract

Key Points:

1. There are three distinct classes of symptoms, functional impairment, and medication burden among older adults with advanced kidney disease.

2. One class with Complex Needs with pain and psychological symptoms, functional difficulties, and polypharmacy may benefit from tailored multidisciplinary care.

Background: Older adults with advanced CKD (stages 4 and 5) have significant symptoms, polypharmacy, and functional difficulties, and previous studies evaluated these burdens separately. Identifying subgroups with similar patterns of burdens could help clinicians optimize care for these individuals.

Methods: We conducted a secondary analysis of 377 older participants (70 years and older) with stage 4 and 5 CKD at high risk of hospitalization enrolled in a national Veterans Affairs prospective cohort study. Adults on dialysis or with prior kidney transplant were excluded. We used latent class analysis to identify participants with similar patterns across symptoms, medication burden, and function. Sixteen variables were included: symptoms (anxiety, depression, appetite, pain, shortness of breath, fatigue, dizziness, leg weakness, constipation, and stiffness using the Symptom Burden Score), polypharmacy (≥10 medications and potentially inappropriate medications), and function (activities of daily living [ADLs], physical and cognitive instrumental ADLs [IADLs], and falls in the past year). We also compared 12-month hospitalization and mortality rates between the three classes.

Results: Three classes of participants with similar functional impairment, medication burden, and symptom phenotypes were identified. The largest participant class (N=208) primarily had difficulties with physical IADLs and polypharmacy. The second participant class (N=99) had shortness of breath, constipation, and dizziness. The third participant class (N=70) had complex needs with daily pain, psychological symptoms (anxiety and depression), functional limitations (ADLs and physical and cognitive IADLs), and polypharmacy. The three classes had significantly different levels of comorbidities, financial stress, and social support. There were no significant differences in mortality and hospitalization among the three classes.

Conclusion: There are distinct classes of older adults with advanced CKD who have physical and psychological symptoms, functional impairment, and medication burden. Tailoring care for this population should include a multidisciplinary team to address these overlapping symptoms, medication, and functional needs.

Graphical abstract

Figure 1

Item response probabilities by latent class and variables. Item response probabilities are the model's estimated probability of a participant endorsing the 16 symptoms, medication burden, and functional impairment items conditional on class membership. Item response probabilities >0.7 are shown in blue. ADL, activity of daily living; IADL, instrumental activity of daily living.