Want to go straight to hot topic. Click on the word
	Psychological and social aspects		Preserving social structures
	Polypharmacy		Evolving renal bone disease
	Ethical problems		Guidelines and recommendations

One of the most remarkable recent developments in nephrology has been the rapid change in the demographics of our patient population.

In the 1970s and 1980s, older patients were not routinely offered dialysis. But now, more than half of the one million chronic dialysis patients world wide are over 65. The dialysis-acceptance rate for patients over 65 is approaching 300 patients per million population (pmp), compared with only 72 pmp in those aged 18 to 641.

To offer our patients the best care, nephrologists increasingly need to appreciate the medical problems which can become more significant in later life. These include:

		immobility;
		instability;
		incontinence;
		intellectual impairment;
		iatrogenic disease; and
		immunosenescence.

By no means all older patients face these difficulties but, for those that do, these issues can have implications for their choice of renal-replacement therapy, treatment tolerance, and quality of life. Each patient must be individually -- and comprehensively -- assessed, including consideration of functional psychological and social issues, to ensure that their renal-replacement modality is suitable.

Most chronic dialysis patients aged over 65 opt for hospital haemodialysis(1) and this is usually for practical or clinical reasons

Psychological and social aspects are central in selecting a dialysis modality. Dialysis is an intensive intervention and while life is maintained it is important that the quality of life achieved is viewed positively by the patient. Depression is common both in older adulthood and in patients with end-stage renal failure. Regular review will help to identify patients who are not coping well.

Preserving social structures is particularly important in patients who may already be at risk of becoming socially isolated. Some older patients find the environment of the dialysis unit socially rewarding. However, regular hospital attendance for haemodialysis may mean giving up daytime activities, such as voluntary work or day-centre visits.

Peritoneal dialysis does offer flexibility and freedom from frequent visits to the hospital, but it means patients have more responsibility for their treatment. If a patient is being helped with their dialysis at home, their carer -- often a family member -- can find this a heavy burden. Care must therefore be taken not to “medicalise” the patient’s core social relationship. An experienced multidisciplinary team should monitor the patient and their family and be prepared to suggest changes if appropriate.

Polypharmacy is a common problem in older patients, and dialysis patients are reported to take an average of seven to nine prescribed drugs. If these are not regularly rationalised, patients can suffer detrimental side-effects without adequate benefit.

Patients with end-stage renal failure are also unique in suffering evolving renal bone disease, often with other risk factors for osteoporosis. This group has a 4.4 RR for hip fracture, with a two-an-one-a-half-times greater one-year mortality(2,3). There is increasing focus on programmes of rehabilitation and on prevention of falls and fractures in older adults but the gravity and impact of end-stage renal failure often means that, in patients receiving renal-replacement therapy, other considerations are subsumed. Older patients with renal failure should receive access to this type of programme where appropriate.

Complex ethical problems will increasingly arise: for example, the difficult situation of patients who are suffering from dementia and cannot understand the demands and implications of renal-replacement therapy; and those patients who have other advanced or unstable co-morbidities.

There are now published guidelines and recommendations in several countries which deal with the withholding and withdrawing of life-support treatments: specifically, in end-stage renal failure, by the UK Renal Association and the American Society of Nephrology. These emphasise the importance of shared decision making, transparency, and good planning -- with full involvement of the nephrologist, multidisciplinary team, primary-care team, patient and their family.

The problems associated with ageing are individual to each patient, constantly evolving, and demand regular, holistic re-evaluation. However, the changing demographics of the nephrology-patient population is a reflection of advances in medical care and, if approached positively, will offer new and rewarding clinical challenges.

Acknowlegement
Thanks to Sue Broome, Renal Nurse Specialist, for advice and comments.