title: The Overuse, Underuse, and Misuse of Dialysis in ESKD Patients with Dementia.
abstract: The profile of patients on chronic dialysis has shifted. There is a growing group of older patients with comorbid dementia and ESKD, who are at risk of overuse, underuse, and misuse of dialysis. Policy is lacking to help guide treatment decisions in this group. This paper explores clinical considerations specific to patients with comorbid ESKD and dementia. These include: the impact of comorbid dementia on dialysis effectiveness and feasibility; burden of care issues that are specific to patients with dementia; and capacity, autonomy, and consent. A better understanding of these issues may help guide discussions and decision making about treatment. For some older patients with multiple comorbidities including dementia, dialysis does not provide survival or quality of life benefit compared to medical management. These patients also experience additional treatment burden due to a 'dementia unfriendly' environment. However, exceptions may include patients who are younger, more independent, and have fewer comorbidities. Patients with dementia are often inappropriately assumed to lack capacity to participate in treatment decision making, and are at risk of having their preferences overlooked. Many patients with mild-to-moderate dementia remain capable of reporting their preferences and quality of life, and should always be involved in treatment discussions where possible.
authors.affiliation: Ballarat Health Services, Ballarat, Victoria, Australia.
authors.forename: Aleece
authors.initials: A
authors.lastname: MacPhail
authors.affiliation: Ballarat Health Services, Ballarat, Victoria, Australia.|Victorian Institute for Forensic Medicine, Department of Forensic Medicine, Monash University, Southbank, Victoria, Australia.
authors.forename: Joseph E
authors.initials: JE
authors.lastname: Ibrahim
authors.affiliation: Australian Centre for Evidence Based Aged Care, La Trobe University, Melbourne, Victoria, Australia.|Centre for Palliative Care, St Vincent's Health, Fitzroy, Victoria, Australia.
authors.forename: Deirdre
authors.initials: D
authors.lastname: Fetherstonhaugh
authors.affiliation: University of Melbourne, Parkville, Victoria, Australia.|Western Health, Footscray Hospital, Footscray, Victoria, Australia.
authors.forename: Vicki
authors.initials: V
authors.lastname: Levidiotis
mesh_terms: D003657:Decision Making; D003704:Dementia / Q000150:complications* / Q000401:mortality; D014943:Global Health; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications / Q000628:therapy*; D011379:Prognosis; D006435:Renal Dialysis; D015996:Survival Rate / Q000639:trends