In Practice
Managing Older Adults With CKD: Individualized Versus Disease-Based Approaches

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The last decade has seen the evolution and ongoing refinement of a disease-oriented approach to chronic kidney disease (CKD). Disease-oriented models of care assume a direct causal association between observed signs and symptoms and underlying disease pathophysiologic processes. Treatment plans target underlying disease mechanisms with the goal of improving disease-related outcomes. Because average glomerular filtrate rates tend to decrease with age, CKD becomes increasingly prevalent with advancing age and those who meet criteria for CKD are disproportionately elderly. However, several features of geriatric populations may limit the utility of disease-oriented models of care. In older adults, complex comorbid conditions and geriatric syndromes are common; signs and symptoms often do not reflect a single underlying pathophysiologic process; there can be substantial heterogeneity in life expectancy, functional status, and health priorities; and information about the safety and efficacy of recommended interventions often is lacking. For all these reasons, geriatricians have tended to favor an individualized patient-centered model of care over more traditional disease-based approaches. An individualized approach prioritizes patient preferences and embraces the notion that observed signs and symptoms often do not reflect a single unifying disease process and instead reflect the complex interplay between many different factors. This approach emphasizes modifiable outcomes that matter to the patient. Prognostic information related to these and other outcomes generally is used to shape rather than dictate treatment decisions. We argue that an individualized patient-centered approach to care may have more to offer than a traditional disease-based approach to CKD in many older adults.

Section snippets

Case 1

A healthy 84-year-old man with mild hypertension and no other comorbid conditions had a glomerular filtration rate (GFR) of 70 mL/min/1.73 m2 (1.17 mL/s/1.73 m2) and no proteinuria. Over several weeks, his GFR decreased to 20 mL/min/1.73 m2 (0.33 mL/s/1.73 m2) and he was found to have proteinuria (2+) and red blood cell casts on urinalysis. On further testing, he had a protein-creatinine ratio of 2,000 mg/g and serologic workup was notable for the presence of a positive antineutrophil

Limitations of a Disease-Based Approach

The last decade has seen the evolution of a disease-based approach to chronic kidney disease (CKD) involving the development, dissemination, and refinement of practice guidelines for this condition (Fig 1).1 These guidelines have served a variety of different purposes that include establishment of a working definition of CKD, systematic review of available evidence, and formulation of treatment strategies and potential performance measures based on available evidence.5, 6, 7

Because

Individualized Patient-Centered Care

Given the limitations of disease-oriented models of care in older populations, geriatricians often favor a more individualized patient-centered approach. The individualized approach prioritizes patient goals and preferences and embraces the notion that observed signs and symptoms may not be the consequence of a single disease process, but instead reflect the complex interplay between a variety of different factors, including pathologic processes, aging, and social and psychological factors (

Disease-Oriented Versus Individualized Patient-Centered Care

Most older adults with CKD will fall somewhere between the 2 extreme cases presented earlier. Unlike the patient described in case 1, clinical presentation and treatment options are unlikely to be shaped by a single underlying pathophysiologic process and most will have competing health priorities and unique preferences. Nevertheless, many will derive some benefit from disease-based interventions, unlike the patient described in case 2. However, these interventions may be most beneficial if

Role of Prognostic Information in Individualized Patient-Centered Care

Although individualized treatment plans are driven by patient preferences and values, accurate prognostic information often is very helpful in crafting these plans. For example, treatment decisions for the patient described in case 3 may depend on her expected risk of progressive loss of kidney function with and without NSAID use. The extent to which the patient described in case 4 and his caregiver prioritize visits to the renal clinic may depend on his expected risk of progressing to

Conclusions

For many older adults who meet the criteria for CKD, an individualized patient-centered approach may have more to offer than the traditional disease-oriented approach. An important feature of the individualized approach is that it can always accommodate disease-based treatment strategies if these are aligned with patient goals and preferences. However, treatment strategies that are informed by only the presence and severity of abnormalities in kidney function (and associated risk information)

Acknowledgements

Support: Support was through a Beeson Career Development Award from the National Institute on Aging to Dr O'Hare and the Birmingham/Atlanta Geriatric Research Education and Clinical Center Special Fellowship in Advanced Geriatrics and John A. Hartford Foundation/Southeast Center of Excellence in Geriatric Medicine to Dr Bowling.

Financial Disclosure: The authors declare that they have no relevant financial interests.

References (55)

  • K/DOQI Clinical Practice Guidelines for Bone Metabolism and Disease in Chronic Kidney Disease

    Am J Kidney Dis

    (2003)
  • K/DOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease

    Am J Kidney Dis

    (2004)
  • J. Coresh et al.

    Prevalence of chronic kidney disease in the United States

    JAMA

    (2007)
  • J.L. Wolff et al.

    Prevalence, expenditures, and complications of multiple chronic conditions in the elderly

    Arch Intern Med

    (2002)
  • S.V. Jassal et al.

    Loss of independence in patients starting dialysis at 80 years of age or older

    N Engl J Med

    (2009)
  • S.E. Strauss et al.

    Evaluation, management, and decision making with the older patient

  • J.D. Piette et al.

    The impact of comorbid chronic conditions on diabetes care

    Diabetes Care

    (2006)
  • C. Ritchie

    Health care quality and multimorbidity: the jury is still out

    Med Care

    (2007)
  • C.M. Boyd et al.

    Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance

    JAMA

    (2005)
  • R.C. Petersen et al.

    Neuropathologic features of amnestic mild cognitive impairment

    Arch Neurol

    (2006)
  • A.D. Rule et al.

    The association between age and nephrosclerosis on renal biopsy among healthy adults

    Ann Intern Med

    (2010)
  • J.M. Flacker

    What is a geriatric syndrome anyway?

    J Am Geriatr Soc

    (2003)
  • M.E. Tinetti et al.

    Shared risk factors for falls, incontinence, and functional dependenceUnifying the approach to geriatric syndromes

    JAMA

    (1995)
  • C.B. Bowling et al.

    Impact of chronic kidney disease on activities of daily living in community-dwelling older adults

    J Gerontol A Biol Sci Med Sci

    (2011)
  • L.F. Fried et al.

    Chronic kidney disease and functional limitation in older people: Health, Aging and Body Composition Study

    J Am Geriatr Soc

    (2006)
  • K.L. Johansen et al.

    Significance of frailty among dialysis patients

    J Am Soc Nephrol

    (2007)
  • L.C. Walter et al.

    Cancer screening in elderly patients: a framework for individualized decision making

    JAMA

    (2001)
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    Originally published online December 22, 2011.

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