The  data does not support early initiation of RRT in geriatric patients (Table 2). As the current NKF recommendations for initiating RRT in a geriatric patient are somewhat vague, it has been proposed that a complete in depth quality of life (QOL) assessment is the best tool to evaluate the geriatric patient’s candidacy for RRT. Ideally, this would consist of a geriatric team evaluation of the patient including a baseline comprehensive geriatric assessment (CGA). Domains to be considered in a CGA are shown in Table 1. Subsequent CGA’s can be useful in making important medical decisions, including if/when to initiate RRT. For the non-geriatrician, many screening tools exist to evaluate a geriatric patient’s QOL and functional ability (Table 1). It is important to remember that dialysis, like any medical resource, will have candidates that range from excellent to poor based not exclusively on age but, on current QOL and prospective QOL maintenance/improvements.
 

TABLE 1

 Table 1 adapted from Reference 1.

Healthy/Usual: The most optimal dialysis patient who might also be a transplant candidate.
 
Vulnerable: A more typical dialysis candidate. Geriatric assessment and intervention plans (e.g., rehabilitation, pain control, treatment of cognitive deficits and depression, limiting polypharmacy, preventing falls, instituting home services) may slow the progression of geriatric susceptibility factors that will adversely effect prognosis, QOL, and the dialysis experience.

Frail: This is a suboptimal dialysis candidate and should be considered for a non-dialytic treatment plan or a time-limited dialysis trial. Final decisions will hinge on patient preferences, QOL, and contextual issues.

Nursing home (NH) patients typically might reflect the frail group outlined in Table 1.  Among a national cohort of NH residents followed 12 months after the initiation of dialysis, 58% had died and pre-dialysis functional status had been maintained in only 13%. In a random-effects model, the initiation of dialysis was associated with a sharp decline in functional status; this decline was independent of age, sex, race, and functional-status trajectory before the initiation of dialysis. The decline in functional status associated with the initiation of dialysis remained substantial, even after adjustment for the presence or absence of an accelerated functional decline during the 3-month period before the initiation of dialysis.(3)

In conclusion, geriatric patients with ESRD should be assessed using functional measures and geriatric assessment principles.  Patient prognosis should be estimated based on this assessment and discussions held about therapeutic options, including foregoing dialysis when the benefits are not clear.