How to manage assisted peritoneal dialysis for the elderly patients Olof Heimbürger, Stockholm, Sweden Chairs: Salvatore Di Giulio, Rome, Italy Thierry Lobbedez, Caen, France Prof. Olof Heimburger Division of Renal Medicine Department of Clinical Science Intervention and Technology Karolinska Institutet Stockholm, Sweden slide 1 Thank you very much. First, I want to thank the organisers for inviting me to beautiful Istanbul. It's very nice to come back here. In this same room, we had the ISPD congress a couple of years ago. So I feel much at home here, which we should do when we dialyse. slide 2
Well, this is a slide I got from Joanne Bargman about the myths about the right PD patient because many of our colleagues particularly in North America I would say, believe a PD patient shouldn't be big, he must be smart and must have a large home. slide 3 Sorry Einstein couldn't because they can't be elderly, slide 4
they need to be young and smart. That's certainly not true. slide 5 From England, it's been shown from the North Thames Dialysis that elderly patients with a large fraction of PD showed similar survival and quality of life with PD and haemodialysis. However, as we heard earlier, many patients are not even considered for PD and there's a bias against using PD in many countries in Europe. If given a choice, as we also heard, about half of the patients will choose if they get the choice in the right way and the right information
and I think this was yes a brilliant talk and I would agree with everything said in that one. slide 6 There are certain things that could be a benefit for elderly patients and I think particularly, the problem we have in our unit and I'm sure other people have it also, is a fistula creation and multiple surgeries in the same patient and in the end the failure to create a functioning vascular access and it ends up with a central tunnelled IJ line which we could avoid with PD and we also have hemodynamic instability. So there are several reasons why PD is a good option for many patients to be considered. slide 7 We know that graft failure is largely in elderly patients. slide 8
From Australian data, we can see that elderly patients have less technique failure on PD. slide 9 They do not even seem to have more peritonitis either. So it seems to be reasonable a good option. We also know from many studies that survival is very similar on PD or HEMO. Perhaps with an initial advantage for PD.
slide 10 We have a large challenge in the world. This is just data from Europe showing the estimated number of elderly people. You can see the 80 plus group, here markedly in the grey one, increasing up to year 2050. We get an older and older population and if we are able to provide dialysis for them, certainly many of them need to go home if not for other reasons for economic reasons. slide 11
When we just looked at this data, a couple of years ago from France showing that the dialysis patients are mainly elderly and that's the same in all countries in Europe I would say. slide 12 Also they have a large number of comorbidities so we have an elderly diseased group of patients. slide 13 In Canada they have done a lot of research on how patients choose and what are the important factors and what are the barriers for self-care. It seems that among the patients that have barriers it's important to have family support if they are to going to do PD by themselves.
slide 14 By the way, in this study they found very few medical contraindications for PD. slide 15 But there are barriers for older people but they are not clearly medical like difficulty in lifting bags, difficulty in handling things, decreased vision, blindness, decreased hearing, deafness, also some cognitive decreased function. Not so easy to learn how to do PD and remember to do it in the right way. So there are certain elderly patients that we believe would do very well on PD and would do it but who can't handle it by themselves but would need some support for doing it. slide 16
There are also psychological barriers that we should remember. slide 17 But what experience do they have with assisted PD in elderly patients? Well, I will go through some data and to start with, I will say that the largest database comes from my previous speaker here in this session from France where they have provided a lot of data from the French PD Registry. But to start with in Denmark Johan Povlsen and Ivarson made an analysis of their patients that had a high frequency of using assisted APD. In their unit, they have caregivers that are in fact employed by the unit and go home and start and terminate APD in the patients. slide 18
They could do it even in end plant patients and had very good results even though the results were better in patients who did the dialysis themselves than in patients who were on assisted PD, that's not a big surprise because of the larger diseased burden in the patient in assisted PD. Of course, there's a reason why they're assisted. slide 19 If they looked at the combined patient technique survival, they found no difference.
slide 20 In France, compared to other countries, a lot of elderly patients were selected for PD in France and why is this? It's because they have excellent logistics system. slide 21 They have private nurses in a countrywide network, which according to this information are 12% of the French nurses. They are directly paid by the public and are allowed to PD. Of the 93, they got a better reimbursement for that and CAPD was the treatment of choice. So there are nurses around that are allowed or willing to do PD and get paid for doing that. So it's an easy system to get to work and I will compare it later with some data from Sweden. slide 22
You can see that of after official recognition of private nurses and an increase in fees, the market grew but it started earlier and it's a system that seems to work in many areas of France at least. slide 23 When they looked at the data, they could see that according to the modality of assistance of elderly patients on PD they enormously did better. But the family assisted did in fact better than the nurse assisted but still if you consider what group of patient this is, it's quite ok you can see they have a 2-year survival here about 50% which is excellent in this diseased group. slide 24
What are the problems of technique failure in these patients? You can see that the lack of assistance is not a large problem. However, I heard from a colleague in Singapore that they had a lot of patients with assisted PD, which had a nurse from the Philippines doing PD. That worked excellently for 2 years and then, they got a lot of peritonitis and that's because the nurses were only allowed to stay 2 years in Singapore. So then they got some new person helping them who was not trained in a proper way. So it's important for this transition and with the logistics in different countries. slide 25 Technique survival, you can see it was also affected by residual renal function as expected and by centre size and I think this is a very important factor for having a success of this.
slide 26 The probability of being peritonitis free was in fact, the best for the family assisted but still the results are comparable to what you see in Europe. I would say that a lot of published data are bias because if you have good results in peritonitis, you publish them but if you have bad results, it's very unlikely that they're published. When you talk to people, it's very common that in Europe they have a peritonitis incidence, about 1 episode in two years around, that is very common. Some units are better but it's common when you talk to people. slide 27
Another important factor is that when the training centre did home visits for the patients, there was a much larger chance that they got peritonitis free because they could adjust and help the nurses that are doing the exchanges at home and monitor what is going on. slide 28 As we saw earlier, the extra cost for nurse assistance is offset by the absence of transport costs to the dialysis centre and the lower cost of PD treatment. So it was cost efficient to do assisted PD at home. It's not the same in all countries, certainly not in Sweden I would say but in France this is very clear that this is the case. To obtain the best results it's mandatory that additional regular visits are done at home by the nurses from the training centre. They also thought that some additional rules should apply: try to work with the same nurses and not have a lot of different staff. When they are working in a group, don't allow them to train new colleagues by themselves. They must be trained by the original centre and I think that's very important. Re-check regularly the knowledge of the caregivers. I think that those are three very good suggestions. slide 29
Well, how is it in other countries? This was a study that was just published in PDI from Brazil where they looked at patient survival in patients with assisted PD and you can see it works even in a low economic country like Brazil with their typical population and with quite good results and very low peritonitis rate in fact. These patients are not only elderly, it was a mixture of patients needing assisted PD. slide 30 If you look here, these are the elderly patients doing either PD themselves or on assisted PD and you can see that the survival is less than this group from Taiwan but still quite good results. slide 31
These are really excellent results from the south of Sweden from Skane where they had a very good programme for assisted PD compared to centre haemodialysis where they compared their assisted PD patients to patients on in-centre haemodialysis matched for age and comorbidity. There's absolutely no difference in survival and you can see that this patient is quite good. It's about 50%, almost 50% 3-year survival, which is a very good result, compared to this diseased patient group. So they were very successful but I will come back to this shortly. slide 32 I will tell you about the project we had in Stockholm for assisted APD slide 33
that was done in the part of our hospital that is in Sauna the previous Karolinska Hospital and the patients were planned for assisted PD at the outpatient clinic or in the renal ward. Home visits were done by the pre-dialysis educational nurse and the PD nurse. The patients were evaluated to be suitable for assisted APD and motivated. Then PD catheter surgery, they got a home alarm. That's something you can get in Sweden if you're elderly that you put on your arm and you can press it if you have a problem if you live alone. That's a very good system to have for these patients. Then they tested the prescription in the renal ward for at least one night. In fact, they tested it until they saw it worked so they could start it at home. So they didn't have catheter problems and things like that. The patients were also taught to turn their alarm off if they got an alarm during the night. So they should know how to do it and this is not difficult, just press the button on the machine. So they could stop. slide 34 They had a lot of practical training of the staff. Maximum 5-6 participants and this was coordinated with the native community nurses, private care nurses and the unit for advanced car at home. But because of the high cost for the unit for advanced care at home for these nurses to go home, this was usually done by the community nurses. In Stockholm we have a very large privatisation of care in general and it could turn out that the community nurses from the centre were taking care of the patients in the daytime but then there were other
private caregivers that were doing it in the night and at the weekend it might be a third caregiver that was responsible. This led to the fact that a lot of people need to be trained. slide 35 So during this project 20 patients started and they stayed on PD for 3-14 months. 57 community nurses were trained. In addition to that, a total of 59 people were trained from 6 private care providers, 6 nursing homes and 6 geriatric wards. In addition 68 people were trained and in addition staff from the units for advanced care at home. So you can see a couple of hundred people trained in the end. So because of logistic reasons, this was quite complicated and the costs of course were very high for all this staff and sometimes these staff and some other staff and also ended up with a lot of people --- to patients which is not good. In Lund where they were very successful I showed the data before, they trained usually out in the countryside. The local nurses or even the patient helper at home but all felt that they should help. But in Stockholm it's always this discussion, this not our responsibility, this should be done by this team and so on. Then you come into the logistical nightmare and get a lot of problems to get things to work. So logistics are extremely important to get this to work and that's why I think the French system seems to be excellent. slide 36
When we look at the regional differences in Sweden as regards to reimbursement and logistics, you can see that there are very large difference between different parts of Sweden where it's very easy to do. You can also notice that in it's quite difficult now because the local authorities from the counties said 'Well, this shouldn't be paid by us' and so on then it practically became impossible to do it in spite of the very good programme that we had. Now we're working on a national level to try to change this and I think there's a good chance that it will be changed but everything takes a long time. slide 37 So to summarise my talk, assisted PD is used to a small extent in many centres, assisted CAPD or APD. In France, the availability of private nurses to assist patients at home allows us to use APD in a large number of patients. Cost varies a lot between countries. Home visits and initial training followed up by the PD centre are important success factors. Best success if not too many people are involved. slide 38 I think there are some key success factors, one of them is reimbursement. Pre-dialysis evaluation and education to find the right patient is also very important. Home visits by the
training centre. Logistics, extremely important. Culture and society, family support, patient and staff education but we also need to remember that dialysis is not always the best choice as we just heard in the previous talk. slide 39 Should we start patients on dialysis or should we continue conservative care and particularly, patients with comorbidity, slide 40 there are some patients that we shouldn't start on dialysis. The other question is when we should we start. I just heard the other day from this -- study that in Germany some units have problems in recruiting patients and they evaluate them when GFR goes below 10 ml/min because all of them haven't started on dialysis. I would say that I have very few times started patients with a GFR about 10 ml/min on dialysis. So it's also a matter of when you should start. You could keep some patients with a low GFR doing well for 5-7 years. So you shouldn't start too early in the elderly diseased patients because you're not helping all of the patients that's my opinion. Thank you very much.
slide 41 I just want to tell you if you're interested in this you can hear much more about at in the EuroPD meeting in Maastricht in October slide 42 and next year at the ISPD meeting in Madrid. Thank you.