Utility of geriatric assessments in evaluation of older adults for kidney transplantation.

BACKGROUND: While kidney transplantation has favorable outcomes in patients aged 65 years and older, many are not referred for evaluation despite having no contraindications. We wanted to determine whether incorporating geriatrics and geriatric assessments (GA), as part of kidney transplant evaluation at the University of Chicago Medicine, would help identify suitable candidates and improve transplantation outcomes among older adults. METHODS: Between 2012 and 2016, as part of their multi-disciplinary transplant evaluation, 171 patients underwent an initial GA with the study geriatrician, who rated them on a five-point scale from "poor" to "excellent," and presented their cases to multidisciplinary transplant review meetings. Patients were followed until June 1st, 2021. Predictor variables included geriatric recommendation, clinical characteristics, and demographics. Outcomes of interest were mortality, receipt of transplant, and waitlist placement. RESULTS: Compared to patients rated "poor," "marginal," or "fair," we found that patients that the geriatrician recommended as "good" or "excellent" were more likely to be waitlisted and receive a transplant. Favorably rated patients were also less likely to be removed from the waitlist due to becoming medically unfit, meaning worsening medical morbidity, frailty, and cognitive status. CONCLUSION: Including geriatricians to perform GAs as part of the transplant evaluation process can help identify suitable elderly candidates.

Patient and provider determinants of nephrology referral in older adults with severe chronic kidney disease: a survey of provider decision making.

BACKGROUND: Although chronic kidney disease (CKD) disproportionately affects older adults, they are less likely to be referred to a nephrologist. Factors that influence the referral decisions of primary care providers (PCPs) specifically for older CKD patients have been incompletely described. Patient factors such as dementia, functional disability, and co-morbidity may complicate the decision to refer an older adult. This study evaluated the role of patient and PCP factors in the referral decisions for older adults with stage 4 CKD. METHODS: We administered a two-part survey to study the decisions of practicing PCPs. First, using a blocked factorial design, vignettes systematically varied 6 patient characteristics: age, race, gender, co-morbidity, functional status, and cognitive status. CKD severity, patient preferences, and degree of anemia were held constant. Second, covariates from a standard questionnaire included PCP estimates of life expectancy, demographics, reaction to clinical uncertainty, and risk aversion. The main outcome was the decision to refer to the nephrologist. Random effects logistic regression models tested independent associations of predictor variables with the referral decision. RESULTS: More than half (62.5%) of all PCP decisions (n = 680) were to refer to a nephrologist. Vignette-based factors that independently decreased referral included older patient age (OR = 0.27; 95% CI, 0.15 to 0.48) and having moderate dementia (OR = 0.14; 95%CI, 0.07 to 0.25). There were no associations between co-morbidity or impaired functional activity with the referral decision. Survey-based PCP factors that significantly increased the referral likelihood include female gender (OR = 7.75; 95%CI, 2.07 to 28.93), non-white race (OR = 30.29; 95%CI, 1.30 to 703.73), those who expect nephrologists to discuss goals of care (OR = 53.13; 95%CI, 2.42 to 1168.00), those with higher levels of anxiety about uncertainty (OR = 1.28; 95%CI, 1.04 to 1.57), and those with greater risk aversion (OR = 3.39; 95%CI, 1.02 to 11.24). CONCLUSIONS: In this decision making study using hypothetical clinical vignettes, we found that the PCP decision to refer older patients with severe CKD to a nephrologist reflects a complex interplay between patient and provider factors. Age, dementia, and several provider characteristics weighed more heavily than co-morbidity and functional status in PCP referral decisions. These results suggest that practice guidelines should develop a more nuanced approach to the referral of older adults with CKD.

Dementia, diagnostic disclosure, and self-reported health status.

OBJECTIVES: To investigate the general awareness of cognitive impairment in persons with documented dementia, evaluate the subject's recall of a diagnostic disclosure from a physician and their recollection of the discussion, and determine whether this awareness of cognitive impairment or the recall of diagnostic disclosure is associated with poorer self-rated health scores. DESIGN: Secondary data analysis. SETTING: Three university-based clinical referral sites for dementia illnesses. PARTICIPANTS: Convenience sample of 149 patients with a diagnosis of dementia. MEASUREMENTS: Bivariate and logistic regression models with the outcome variables of patient self-report of memory problems, patient report of being told about memory problems by a physician, and self-reported health scores. RESULTS: Ninety-six of 149 (64.4%) subjects reported that they had memory problems, and this report was independently associated with younger age (P=.01) and higher Mini-Mental State Examination score (P=.02). Thirty-nine (26.2%) subjects reported being told by a physician about a diagnosis of dementia or memory problems. This recall was associated with younger age (P<.001), male sex (P=.04), and higher education level (P=.02). African Americans reported poorer self-rated health scores (odds ratio (OR)=2.4, 95% confidence interval (CI)=1.1-5.1). Persons who reported being told by a physician of a diagnosis of dementia were more likely to report poorer self-rated health (OR=2.5, 95% CI 1.1-5.5). CONCLUSION: Further research is needed to elucidate the relationship between self-rated health and dementia specifically focusing on the potentially negative effects of diagnostic disclosure on self-rated health, further identification of factors that contribute to self-rated health in persons with dementia, and the prognostic value of self-rated health for persons with dementia.