Geriatric Assessment in Older Patients with Advanced Kidney Disease: A Key to Personalized Care and Shared Decision-Making-A Narrative Review

Abstract

As the global population ages, so too does the prevalence of older people with chronic kidney disease (CKD). Helping people age well with CKD and supporting older people with end-stage kidney disease (ESKD) to make personalized decisions regarding kidney replacement therapy (KRT) or conservative care (CC) are an essential component of care. However, these factors are relatively underreported in both the fields of nephrology and geriatric medicine, and prospective, randomized evidence is lacking. This narrative review article, authored by both nephrologists and geriatricians, discusses specific geriatric issues that arise in older people with CKD and why they matter. The available evidence for KRT or CC in older people with frailty is outlined. The importance of performing a comprehensive geriatric assessment, or a modified nephrogeriatric assessment, to ensure a systematic evaluation of the person's medical problems and life needs, goals, and values is described. We consider different models of nephrogeriatric care and how they may be implemented. Kidney supportive care-addressing an individual's symptoms and overall well-being alongside the more traditional nephrological principles of preventing disease progression and optimizing risk-is highlighted throughout the article. We outline ways of identifying the later stages of a person's disease journey, when transition to palliative care is indicated, and elaborate methods of preparing patients for this through multidisciplinary advance care planning. Finally, we discuss practice and systems for nephrogeriatric care in five different European countries and consider future directions, challenges, and highlights in this rapidly evolving, increasingly relevant field.

Keywords: end-stage kidney disease; geriatric assessment; older patients; shared decision-making; treatment pathways.

Figure 1

Multidisciplinary approach in the care of older patients with ESKD. ACP: advance care planning; HRQOL: health-related quality of life; SDM: shared decision-making; RRT: renal replacement therapy.

Figure 2

Spectrum of palliative care in older patients along their CKD trajectory. CKD: chronic kidney disease; ESKD: end-stage kidney disease; NTX: kidney transplantation; CC: conservative care; KRT: kidney replacement therapy; ACP: advance care plan; GP: general practitioner; NEPH: nephrologist; GER: geriatrician; PCP: palliative care physician; NHP: nursing home physician. Adapted from original conceptualization by World Health Organization (WHO).