Design of a consensus-based geriatric assessment tailored for older chronic kidney disease patients:results of a pragmatic approach

PURPOSE: Unidentified cognitive decline and other geriatric impairments are prevalent in older patients with advanced chronic kidney disease (CKD). Despite guideline recommendation of geriatric evaluation, routine geriatric assessment is not common in these patients. While high burden of vascular disease and existing pre-dialysis care pathways mandate a tailored geriatric assessment, no consensus exists on which instruments are most suitable in this population to identify geriatric impairments. Therefore, the aim of this study was to propose a geriatric assessment, based on multidisciplinary consensus, to routinely identify major geriatric impairments in older people with advanced CKD. METHODS: A pragmatic approach was chosen, which included focus groups, literature review, inventory of current practices, an expert consensus meeting, and pilot testing. In preparation of the consensus meeting, we composed a project team and an expert panel (n = 33), drafted selection criteria for the selection of instruments, and assessed potential instruments for the geriatric assessment. RESULTS: Selection criteria related to general geriatric domains, clinical relevance, feasibility, and duration of the assessment. The consensus-assessment contains instruments in functional, cognitive, psychological, somatic, patient preferences, nutritional status, and social domains. Administration of (seven) patient questionnaires and (ten) professional-administered instruments, by nurse (practitioners), takes estimated 20 and 40 min, respectively. Results are discussed in a multidisciplinary meeting including at least nephrology and geriatric expertise, informing nephrology treatment decisions, and follow-up interventions among which comprehensive geriatric assessment. CONCLUSION: This first multidisciplinary consensus on nephrology-tailored geriatric assessment intent to benefit clinical care and enhance research comparability for older patients with advanced CKD

Geriatric Assessment in CKD Care: An Implementation Study

Rationale & Objective: Older people with progressive chronic kidney disease (CKD) have complex health care needs. Geriatric evaluation preceding decision making for kidney replacement is recommended in guidelines, but implementation is lacking in routine care. We aimed to evaluate implementation of geriatric assessment in CKD care. Study Design: Mixed methods implementation study. Setting & Participants: Dutch nephrology centers were approached for implementation of geriatric assessment in patients aged ≥70 years and with an estimated glomerular filtration rate of ≤20 mL/min/1.73 m2. Quality Improvement Activities/Exposure: We implemented a consensus-based nephrology-tailored geriatric assessment: a patient questionnaire and professionally administered test set comprising 16 instruments covering functional, cognitive, psychosocial, and somatic domains and patient-reported outcome measures. Outcomes: We aimed for implementation in 10 centers and 200 patients. Implementation was evaluated by (i) perceived enablers and barriers of implementation, including integration in work routines (Normalization Measure Development Tool) and (ii) relevance of the instruments to routine care for the target population. Analytical Approach: Variations in implementation practices were described based on field notes. The postimplementation survey among health care professionals was analyzed descriptively, using an explanatory qualitative approach for open-ended questions. Results: Geriatric assessment was implemented in 10 centers among 191 patients. Survey respondents (n = 71, 88% response rate) identified determinants that facilitated implementation, ie, multidisciplinary collaboration (with geriatricians) -meetings and reports and execution of assessments by nurses. Barriers to implementation were patient illiteracy or language barrier, time constraints, and patient burden. Professionals considered geriatric assessment sufficiently integrated into work routines (mean, 6.7/10 ± 2.0 [SD]) but also subject to improvement. Likewise, the relevance of geriatric assessment for routine care was scored as 7.8/10 ± 1.2. The Clinical Frailty Score and Montreal Cognitive Assessment were perceived as the most relevant instruments. Limitations: Selection bias of interventions’ early adopters may limit generalizability. Conclusions: Geriatric assessment could successfully be integrated in CKD care and was perceived relevant to health care professionals. Plain-Language Summary: The number of older persons with kidney failure is increasing, many of whom have cognitive decline or are dependent on others for daily life tasks. These problems are often overlooked but relevant for future treatment choices, and they affect quality of life. We asked 10 health care centers to use tests and questionnaires to identify these issues, thus being able to offer additional support. We learned that it is possible to use these assessments in practice and that professionals found them relevant. Collaboration with geriatric departments was perceived valuable. However, there are also challenges, such as not having enough time and personnel and burden to patients. Understanding these possibilities and challenges is crucial for improving care for older patients with kidney failure

A systematic review on the epidemiological data of erythema nodosum leprosum, a type 2 leprosy reaction.

BACKGROUND: Erythema Nodosum Leprosum (ENL) is a humoral immunological response in leprosy that leads to inflammatory skin nodules which may result in nerve and organ damage, and may occur years after antibiotic treatment. Multiple episodes are frequent and suppression requires high doses of immunosuppressive drugs. Global occurrence is unknown. METHODOLOGY/PRINCIPAL FINDINGS: Systematic review of evidence on ENL incidence resulted in 65 papers, predominantly from India (24) and Brazil (9), and inclusive of four reviews. Average incidences are based on cumulative incidence and size of study populations (n>100). In field-based studies 653/54,737 (1.2%) of all leprosy cases, 194/4,279 (4.5%) of MB cases, and 86/560 (15.4%) of LL cases develop ENL. Some studies found a range of 1-8 per 100 person-years-at-risk (PYAR) amongst MB cases. Hospital samples indicate that 2,393/17,513 (13.7%) of MB cases develop ENL. Regional differences could not be confirmed. Multiple ENL episodes occurred in 39 to 77% of ENL patients, with an average of 2.6. Some studies find a peak in ENL incidence in the first year of treatment, others during the second and third year after starting MDT. The main risk factor for ENL is a high bacteriological index. CONCLUSIONS/SIGNIFICANCE: Few studies reported on ENL as a primary outcome, and definitions of ENL differed between studies. Although, in this review averages are presented, accurate data on global and regional ENL incidence is lacking. Large prospective studies or accurate surveillance data would be required to clarify this. Health staff needs to be aware of late reactions, as new ENL may develop as late as five years after MDT completion, and recurrences up to 8 years afterwards

Incidence of ENL in hospital populations (n>100).

*<p>It should be noted here that cumulative incidence is presented as these have been published, although not all numbers could be traced and justified after conducting calculations while some inconsistencies were noticed. So therefore, these numbers should be treated with caution.</p>†<p>Studies that conducted slit skin smears. Studies not indicated with this footnote did not provide information on conducting slit skin smears.</p>‡<p>Assessed late leprosy reaction during surveillance that started after MB-MDT course until smear negativity. This study is excluded from the calculations.</p>§<p>Assessed admissions due to leprosy reactions. This study is excluded from the calculations because n is not well defined.</p

Flow diagram of included studies.

<p>Flow diagram of included studies.</p

Incidence of ENL in field based studies (n>100).

*<p>It should be noted here that cumulative incidence is presented as these have been published, although not all numbers could be traced and justified after conducting calculations while some inconsistencies were noticed. So therefore, these numbers should be treated with caution.</p>†<p>Studies that conducted slit skin smears. Studies not indicated with this footnote did not provide information on conducting slit skin smears.</p

Findings on multiple episodes, number and duration of ENL episodes.

†<p>Only cases with multiple episodes of ENL reported, this accounted for 28.4% of MB cases. This study is excluded from the calculations.</p>‡<p>49 (45%)single, 27 (25%) two, 13 (12%) three, 6 (5%)four, 2 (2%) five, 5 (5%) >five episodes.</p>§<p>45(49%) single, 28 (30%)two, 14 (11%) three, 5 (5%) four or more episodes.</p>**<p>Of the original cohort of 116 patients, 28 were excluded because they had too short follow-up and could not be categorized.</p>††<p>37.5% having acute multiple ENL (i.e. more than one episode lasting less than six months, steady decrease in steroid tapering) and 62.5% chronic ENL (i.e. episode lasting for more than six months).</p>‡‡<p>13 (25%)single, 12 (24%)two, 14 (27%)three, 11(22%)four, 1(2%)five episodes.</p>§§<p>Vaccine versus control group; 3 vs 3 single, 4 vs 4 two, 3 vs 2 three, 0 vs 3 more than three episodes.</p>***<p>An episode of ENL was taken as a separate event if more than 3 months had elapsed since the last episode.</p

Incidence of ENL reported per person years at risk.

<p>(A) Incidence for studies reporting incidence per 100 PYAR. (B) Incidence over time during different study periods for a Bangladesh <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0002440#pntd.0002440-Richardus2" target="_blank">[43]</a> and Ethiopian <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0002440#pntd.0002440-Saunderson1" target="_blank">[41]</a> study.</p

Variation in proportion of cases developing ENL.

<p>(A) Incidence (%) for studies reporting for BB cases. (B) Idem for BL cases and (C) LL cases.</p