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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2020  |  Volume : 31  |  Issue : 4  |  Page : 767-774
The Prevalence of Frailty and its Association with Cognitive Dysfunction among Elderly Patients on Maintenance Hemodialysis: A Cross-Sectional Study from South India


1 Department of Nephrology, Iqraa International Hospital and Research Center, Kozhikode, Kerala, India
2 Department of Nephrology, Aster MIMS Hospital, Kozhikode, Kerala, India
3 Department of Psychiatry, Iqraa International Hospital and Research Center, Kozhikode, Kerala, India

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Date of Submission13-Jan-2019
Date of Decision20-Mar-2019
Date of Acceptance23-Mar-2019
Date of Web Publication15-Aug-2020
 

   Abstract 


Data are scarce regarding the prevalence of frailty in elderly patients undergoing maintenance hemodialysis (HD) in India. We conducted a cross-sectional observational study aimed to study the prevalence of frailty and cognitive dysfunction in patients aged 75 years or more undergoing maintenance HD in three tertiary care hospitals and associated stand-alone dialysis centers in North Kerala. Frailty was ascertained by two methods. In method 1 (physical performance measurement based), dichotomous scoring (0 or 1) of five domains, namely weight loss, exhaustion, low physical activity, weak grip, and slow walking, was done, and a score of 3/5 was used to define frailty. In method 2 (self-report measure based), scores on the Medical Outcomes Study Short-Form 36-item Questionnaire (SF-36) physical function domain were used instead of hand grip strength and walking speed, and a score of <75 was defined as meeting the criteria for weakness and slow walking. Cognitive function was documented using the Montreal Cognitive Assessment Instrument. A total of 899 patients were screened, of whom 44 were aged 75 years or more and 39 met the criteria for inclusion. The majority (n = 31, 79.5%) had ages between 75 and 80 years and were male. Dialysis vintage was <1 year in 15.4%, 1–3 years in 51.3%, and >3 years in 33.3% of patients. Frailty was documented in 22 (56.4%) patients by method 1 and in 25 (64.1%) by method 2. There was a statistically significant difference between the two methods in documenting frailty (P < 0.001, Chi-square test). Cognitive impairment was present in 89.7% of patients and significantly associated with frailty (P < 0.001, Fisher’s exact test). Frailty and cognitive dysfunction are highly prevalent in elderly people undergoing maintenance HD in North Kerala. Physical performance and self-report measure-based methods correlate well in frailty documentation.

How to cite this article:
Gopinathan JC, Hafeeq B, Aziz F, Narayanan S, Aboobacker IN, Uvais N A. The Prevalence of Frailty and its Association with Cognitive Dysfunction among Elderly Patients on Maintenance Hemodialysis: A Cross-Sectional Study from South India. Saudi J Kidney Dis Transpl 2020;31:767-74

How to cite this URL:
Gopinathan JC, Hafeeq B, Aziz F, Narayanan S, Aboobacker IN, Uvais N A. The Prevalence of Frailty and its Association with Cognitive Dysfunction among Elderly Patients on Maintenance Hemodialysis: A Cross-Sectional Study from South India. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2020 Sep 27];31:767-74. Available from: http://www.sjkdt.org/text.asp?2020/31/4/767/292310



   Introduction Top


Population aging is a worldwide phenomenon. India is undergoing a demographic transition. While 8% of its population was recorded 60 years and above in 2011 Census, according to United Nations Population Division, India will experience a considerable growth of 64% in its elderly population between 2015 and 2030.[1]

Frailty is a multidimensional construct or a biological syndrome with multiple causes and contributors that is characterized by diminished strength, endurance, and reduced physiologic function that increase an individual’s vulnerability to increased risk for disability, hospitalization, institutionalization, and death.[2] Frailty is the result of a progressive and sustained degeneration in multiple physiological systems and a declining psychological health in the setting of inadequate social support.[3] Although frailty is an inevitable part of aging, its prevention and postponement is an essential part of a healthy and better quality of life among older adults. In population studies, the prevalence of frailty among population elder than 65 years ranges from 6.9% to 27.3% in developed countries.[4] A recent meta-analysis found 17.4% [95% confidence interval (CI): 14.4% to 20.7%] random-effects pooled prevalence of frailty among low-income countries.[5] This study also found that frailty was significantly higher in women compared with men and, as expected, increased with age.

Chronic kidney disease (CKD) is a major public health problem especially among the elderly affecting more than one-third of all individuals over age 65 years.[6] According to the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), in 2015, approximately two-thirds of prevalent dialysis patients were ≤ 65 years old and one-third were ≤ 75 years old.[7] Frailty is expected to be more common among patients with CKD on maintenance hemodialysis (HD) than community- dwelling older adults due to multiple reasons, and studies have reported a frailty prevalence of > 60% in dialysis-dependent CKD patients, which is independently linked with adverse clinical outcomes in all stages of CKD.[8] Older patients with advanced CKD often have a reduced energy intake which contributes to sarcopenia and, subsequently, physical frailty. This reduced energy intake is due to anorexia resulting from uremia, inflammation, comorbid illnesses, medications, cognitive impairment, and depression. Furthermore, restricting dietary phosphate intake, poor physical activity, elevated pro-inflammatory cytokines including interleukin-6 and tumor necrosis factor-alpha, metabolic acidosis resulting in protein catabolism by activating caspase-3 and the ubiquitin proteasome system, prolactin retention which impairs the production of gonado- tropic hormones such as testosterone, low 25- hydroxyvitamin D levels, cellular senescence, loss of telomeric structures, mitochondrial dysfunction, increased free radical production, and poor DNA repair capability are other important factors contributing to frailty among elderly patients with CKD on maintenance HD.[9]

The prevalence of frailty among patients with CKD on maintenance HD varies significantly in different studies from various parts of the world. A study from Egypt reported 60% prevalence of frailty among 140 HD patients with a mean age of 48 ± 18.3 years.[4] Another study from Brazil reported a lower prevalence (37.8%) of frailty among patients on HD, indicating the large differences of frailty prevalence across different populations.[10]

Furthermore, the lack of consensus about the exact definition of frailty and the absence of a gold standard frailty assessment instruments, also contributed to the large differences of frailty prevalence across studies. Therefore, along with studying the prevalence of frailty in CKD patients on HD, it is important to identify whether disagreement in frailty measurements also plays a role.[11] The aim of this study is to establish the prevalence of frailty in elderly patients with CKD on maintenance HD, measured with two assessment instruments: physical performance measurement based and self-report measure based, in one population and to determine the correlates of frailty among the elderly patients on maintenance HD, in South India.


   Materials and Methods Top


This cross-sectional study was carried out in the HD unit of three tertiary care hospitals and associated stand-alone centers. The study was approved by the institutional review board of the hospitals. Eligible participants included patients aged 75 years or more with a stable clinical condition, a good verbal agreement to questionnaire and on maintenance HD therapy for at least six months, and willing to give written informed consent. Dialysis was performed three times weekly using 3.5 mEq/L dialysate calcium, and the duration of each dialysis was 4 h. The demographic and clinical information of the participants was collected using a structured pro forma. All participants gave written informed consent to participate in this study.

A total of 899 patients who were undergoing maintenance HD in the HD unit of three tertiary care hospitals and associated standalone centers were screened, of which 44 patients (4.89%) were found to be > 75 years at the time of enrollment. The exclusion criteria were patients who have not completed 3 months on maintenance HD, patients <75 years of age, and patients who did not consent to be part of the study. Two patients refused consent. Two patients were excluded because the criterion of three months on maintenance HD was not completed. One patient died before data collection [Figure 1].
Figure 1: Flowchart of the study.

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At enrollment, the primary author collected medical information from the medical charts, including diagnosed comorbidities. The participants were asked to complete a questionnaire and performed a set of function tests supervised by the Frailty was ascertained by two methods. In method 1 (physical performance measurement based), dichotomous scoring (0 or 1) of five domains, namely weight loss, exhaustion, low physical activity, weak grip, and slow walking, was done, and a score of 3/5 was used to define frailty. In method 2 (a self-report primary author measure based), scores on the Medical Outcomes Study Short- Form 36-item Questionnaire (SF-36) physical function domain were used instead of handgrip strength and walking speed, and a score of <75 was defined as meeting the criteria for weakness and slow walking.[12]

Cognitive function was assessed using the Montreal Cognitive Assessment.[13] It assesses cognitive function in seven domains with scores ranging from 0 to 30. It has advantages over the widely used Mini-Mental State Examination. This is because it assesses executive function, a domain that is commonly affected in patients with CKD. It has been shown to be sensitive to changes in cognition in patients on dialysis. A score <26 is suggestive of cognitive impairment, although a cutoff of 24 has been suggested for HD patients.[14]


   Results Top


A total of 899 patients who were undergoing maintenance HD in the HD unit of three tertiary care hospitals and associated standalone centers were screened, of which 44 patients (4.89%) were found to be aged 75 years or more. Out of the 44 patients, 39 (88.64%) met the criteria for inclusion.

The majority (n = 31, 79.5%) had ages between 75 and 80 years, and the mean age of the sample was 78.03% ± 3.90. Nearly 79.5% of the participants were male. The most common diagnosis was diabetic nephropathy (43.6%) followed by hypertensive nephrosclerosis (23.1%). Almost 48.7% of the patients had comorbid cardiovascular disease, 35.9% had coronary artery disease, 20.5% had a cerebro- vascular accident, and 2.6% had peripheral vascular disease. Nearly 97.4% of the participants had arteriovenous fistula (AVF) as the current vascular access. Dialysis vintage was <1 year in 15.4%, 1–3 years in 51.3%, and > 3 years in 33.3%. The sociodemographic and clinical details are summarized in [Table 1].
Table 1: Sociodemographic and clinical data.

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Frailty was documented in 22 (56.4%) patients by method 1 and in 25 (64.1%) by method 2. A weak grip strength (71.8%) was the most common factor among frailty criterion followed by physical activity (69.2%), slow walking (56.4%), and exhaustion (33.3%) [Table 2]. There was a statistically significant difference between the two methods in documenting frailty (P < 0.001, Chi-square test) [Table 3].
Table 2: Prevalence of frailty and cognitive impairment.

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Table 3: Comparison of frailty with two methods.

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Cognitive impairment was present in 89.7% of patients. Mild cognitive impairment was present in 38.5% of the sample, moderate cognitive impairment was present in 25.6% of the sample, and severe cognitive impairment was present in 25.6% of the sample [Table 2]. Cognitive impairment was found to be statistically significantly associated with frailty (P < 0.001, Fisher’s exact test) [Table 4].
Table 4: Correlation between frailty and comorbid disorders.

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   Discussion Top


In this cross-sectional study of adults aged 75 years or more undergoing HD, the prevalence of frailty was found to be 56.4% with method 1 and 64.1% with method 2, and the difference in the prevalence was found to be significant. Patients having cognitive impairment had a significantly higher prevalence of frailty. The self-report measure-based frailty assessment (method 2) has a lower cutoff point for the definition of frailty as more patients were identified as frail, in comparison with the physical performance measurement-based frailty assessment (method 1) in this dialysis population.

To our knowledge, this is the first study that measured frailty prevalence in a population of CKD patients on maintenance HD aged 75 years or more and the first study assessing frailty among patients on maintenance HD from the Indian context. The prevalence of frailty in this population is much higher than the prevalence reported among community- dwelling elderly people from low-income countries.[5] However, this high prevalence was consistent with a previous study of Johansen et al,[8] who found that 67.7% of dialysis patients were frail and Mahmoud et al,[4] who found 60% prevalence of frailty in an Egyptian population of patients with CKD with a mean age of 48 ± 18.3 years. Another study by Bao et al. found that 73% of HD patients were frail.[15] However, the mean age of our patients was much higher when compared to that of past studies, and the expected higher prevalence in frailty with increasing mean age was not found in our study. The probable explanation for this unexpected finding could be that those patients who survive beyond 75 years with CKD would be having a better physical condition and may have a lesser chance of having frailty. Hence, the current understanding regarding the linear relationship between the prevalence of frailty and age needs further clarification.

The average age in this study was 78.03 (±3.90) years. There are only very few studies exploring frailty in this age range. Two studies carried out in Brazil showed that the average age of the participants was 70.0 (±7.5) years and 71.1 (±6.8), respectively.[10],[16] The predominance of males in this study is similar to that of other researches. This shows that male people could be more susceptible to having this disease.[16] In relation to the clinical variables, the results showed that the most predominant underlying disease was the diabetic nephropathy (43.6%) followed by hypertensive nephrosclerosis (23.1%). In a recent study about the health-related quality of life and its determinants in patients with CKD from India, the most common etiology was CKD of unidentified etiology (CKDu) followed by diabetic nephropathy.[17] Concerning vascular access, 76.7% had AVF as the vascular access, which is believed to be the best way of vascular access to perform HD in elderly people. However, the complications resulting from vascular access lead to an increase in the elderly’s morbidity and a rise in costs.[16]

Our study also found very high prevalence of cognitive impairment among the participants. Similar to our finding, a recent systematic review found that, in cross-sectional and longitudinal studies, cognitive impairment and incident cognitive impairment, respectively, were more common in CKD patients when compared to people without CKD.[18] The prevalence of cognitive impairment in CKD patients on maintenance HD has been estimated at 30%–80%.[19] Poor cognitive function among patients with CKD has been linked to poor health literacy, poorer medication adherence, worse physical and mental health, and greater morbidity, and it is a significant predictor of mortality among dialysis popu- lation.[20] Considering the very high prevalence of cognitive impairment among CKD patients aged 75 years and above, our study results supports the ideas of routine screening of cognitive impairment in this population as early recognition can help in the identification and treatment of potentially reversible causes such as delirium and depression.[21] Furthermore, early detection can provide an opportunity for care planning before the dementia becomes advanced. There are several factors contributing to cognitive impairment among CKD patients on HD such as the effect of uremic toxins on neurons, accelerated atherosclerosis, anemia, and serum albumin levels.[22] We also found a significant association between frailty and cognitive impairment among our study population. Along with several common factors that predispose patients with CKD to both frailty and cognitive impairment, the reduction in food intake among CKD patients with cognitive impairment also contributes to frailty.[2]

Our study generated two significantly different prevalence of frailty in a single population with two kinds of measures. The performance- based measurement (method 1) detected frailty significantly lesser when compared to self- report-based measurement (method 2). Such a discrepancy in the prevalence of frailty was reported in past studies also both in the general older population and in the CKD population depending on the method employed.[9] The performance-based frailty phenotype (FP) described frailty as a clinical syndrome involving at least three of the following: unintentional weight loss, self-reported exhaustion, weakness, slow walking speed, and low physical activity. The FP has been used in several studies involving patients with CKD. Recently, due to the practical issues related to the measurement of weakness and walking speed, specifically the time and equipment needed to complete the assessments, several studies of CKD populations have used modified versions of the FP, often substituting questionnaire-based assessments for the objective measures of weakness and slowness. However, similar to our results, many studies showed that questionnaire-based methods of assessing frailty are more likely to overestimate the prevalence of frailty, although they still appear to be predictive of outcomes.[9]


   Conclusion Top


In this study, frailty among elderly CKD patients on HD was found to be high with two measurements. Moreover, cognitive impairment was found to be significantly associated with frailty. As the population of geriatric patients on HD is growing, frailty will become an important subject of clinical care, as it is associated with poor clinical outcomes, falls, disability, hospitalization, and mortality. Hence, it is important to identify those who are frail in order to provide comprehensive care to improve the outcome for this vulnerable population.

Conflict of interest: None declared.



 
   References Top

1.
Chaudhary M, Arokiasamy P. Patterns of frailty and quality of life among older adults: Comparative analysis using SAGE states of India. Population Ageing 2019;12:1-23.  Back to cited text no. 1
    
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Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet 2013;381:752-62.  Back to cited text no. 2
    
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Carrero JJ, Stenvinkel P, Cuppari L, et al. Etiology of the protein-energy wasting syndrome in chronic kidney disease: A consensus statement from the International Society of Renal Nutrition and Metabolism (ISRNM). J Ren Nutr 2013;23:77-90.  Back to cited text no. 3
    
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Mahmoud AA, Fouad M, Deraz H. Prevalence and correlates of frailty among patients on maintenance hemodialysis. Gen Med (LosAngel). 2015;3:156.  Back to cited text no. 4
    
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Johansen KL, Chertow GM, Jin C, Kutner NG. Significance of frailty among dialysis patients. J Am Soc Nephrol 2007;18:2960-7.  Back to cited text no. 8
    
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Nixon AC, Bampouras TM, Pendleton N, Woywodt A, Mitra S, Dhaygude A. Frailty and chronic kidney disease: Current evidence and continuing uncertainties. Clin Kidney J 2018; 11:236-45.  Back to cited text no. 9
    
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Mansur HN, Damasceno Vde O, Bastos MG. Prevalence of frailty in patients in chronic kidney disease on conservative treatment and on dialysis. J Bras Nefrol 2012;34:153-60.  Back to cited text no. 10
    
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Drost D, Kalf A, Vogtlander N, van Munster BC. High prevalence of frailty in end-stage renal disease. Int Urol Nephrol 2016;48:1357- 62.  Back to cited text no. 11
    
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Johansen KL, Dalrymple LS, Delgado C, et al. Comparison of self-report-based and physical performance-based frailty definitions among patients receiving maintenance hemodialysis. Am J Kidney Dis 2014;64:600-7.  Back to cited text no. 12
    
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Tiffin-Richards FE, Costa AS, Holschbach B, et al. The Montreal Cognitive Assessment (MoCA) – A sensitive screening instrument for detecting cognitive impairment in chronic hemodialysis patients. PLoS One 2014;9: e106700.  Back to cited text no. 13
    
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San A, Hiremagalur B, Muircroft W, Grealish L. Screening of cognitive impairment in the dialysis population: A scoping review. Dement Geriatr Cogn Disord 2017;44:182-95.  Back to cited text no. 14
    
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Orlandi FdS, Gesualdo GD. Assessment of the frailty level of elderly people with chronic kidney disease undergoing hemodialysis. Acta Paulista Enfermagem 2014;27:29-34.  Back to cited text no. 16
    
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Manavalan M, Majumdar A, Harichandra Kumar KT, Priyamvada PS. Assessment of health-related quality of life and its determinants in patients with chronic kidney disease. Indian J Nephrol 2017;27:37-43.  Back to cited text no. 17
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Etgen T, Chonchol M, Förstl H, Sander D. Chronic kidney disease and cognitive impairment: A systematic review and meta-analysis. Am J Nephrol 2012;35:474-82.  Back to cited text no. 18
    
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Griva K, Stygall J, Hankins M, Davenport A, Harrison M, Newman SP. Cognitive impairment and 7-year mortality in dialysis patients. Am J Kidney Dis 2010;56:693-703.  Back to cited text no. 19
    
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Bronas UG, Puzantian H, Hannan M. Cognitive impairment in chronic kidney disease: Vascular milieu and the potential therapeutic role of exercise. Biomed Res Int 2017;2017: 2726369.  Back to cited text no. 20
    
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Berger I, Wu S, Masson P, et al. Cognition in chronic kidney disease: A systematic review and meta-analysis. BMC Med 2016;14:206.  Back to cited text no. 21
    
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Lee SH, Cho A, Min YK, Lee YK, Jung S. Comparison of the Montreal Cognitive Assessment and the Mini-Mental State Examination as screening tests in hemodialysis patients without symptoms. Ren Fail 2018;40: 323-30  Back to cited text no. 22
    

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Correspondence Address:
Benil Hafeeq
Department of Nephrology, Iqraa International Hospital and Research Center, Kozhikode
India
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DOI: 10.4103/1319-2442.292310

PMID: 32801237

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