Rehabilitation of the Geriatric Dialysis Patient Janine Farragher and Sarbjit Vanita Jassal Department of Nephrology, University Health Network, Toronto, Canada ABSTRACT Dialysis is offered to patients with end-stage renal disease as a life-sustaining therapy. However, studies have shown that elderly patients experience high rates of functional disability, hospitalization, institutionalization, and mortality on chronic dialysis therapy, and that the initiation of dialysis is in fact associated with an acceleration in functional decline. These findings have sparked debate about the utility of dialysis for elderly renal patients. In this article, it is proposed that geriatric rehabilitation can prevent, reverse or delay the onset of func- tional disability and associated adverse outcomes in older dial- ysis patients, and thus should be incorporated routinely into standard geriatric dialysis care. We outline the causes of dis- ability in elderly dialysis patients, and demonstrate the poten- tial impact of rehabilitation using a case scenario. Models of rehabilitation that have been shown to be effective in improv- ing outcomes for elderly renal and nonrenal populations, including inpatient rehabilitation, exercise training, falls prevention, and home-based models, are reviewed. Geriatric syndromes such as falls, frailty, cognitive impairment and depression are highly common among older dialysis patients. Over 50% have reported depend- ing on others for assistance with basic activities of daily living, while over 95% receive help for instrumental activities of daily living (1). These indicators of poor functioning appear to be associated with adverse out- comes such as hospitalizations, institutionalization, and mortality (2–5). However, with medical rehabilitation, functional dependence and disability can be prevented, reversed, or delayed, particularly when identified and addressed in their early stages. Rehabilitation specialists work in a wide variety of areas to provide patient education, therapeutic exercises, assistive devices, and skills training to those with some form of disability. One of the commonly recognized sub- specialty areas of rehabilitation is postamputation reha- bilitation, where patients are fitted with a prosthesis (an assistive device) and trained how to regain their balance, mobility, and day-to-day functionality. Cardiac, stroke, and geriatric rehabilitations are other well-established subspecialty areas available to patients and healthcare teams across many parts of the developed world. Geriat- ric rehabilitation is geared to improve the functional abilities of the older patient and their caregivers, through retraining (e.g., retraining weakened muscle groups), activity adaptation (e.g., introducing specialized tools for lower limb dressing), and / or modification of their everyday environment (e.g., use of a raised toilet seat). Both patients and their caregivers are taught strategies to reduce the chances of injury and to decrease dependency. Within nephrology, we believe there are many oppor- tunities to incorporate the principles of rehabilitation into the current model of dialysis (and predialysis) care. This article outlines the origins of functional dependence in older dialysis patients, demonstrates how rehabilita- tion can delay or prevent the onset of disability and dependence, and describes the utility of rehabilitation in geriatric nephrology practice. A case example is used to illustrate key points. Case Example: Mr. B Mr. B, a 74-year-old man with end-stage renal disease, is admitted to hospital after falling at home on a Friday evening. He has a 6-year history of chronic kidney disease, and had an arteriovenous fistula created in his left arm one year ago in preparation for hemodialysis. Eight months ago he commenced regular thrice-weekly in-center hemod- ialysis (HD). His past medical history includes an old war injury resulting in an above-knee amputation at the age of 24 years, type II diabetes, hypertension, and coronary artery disease that is well-controlled since 4-vessel bypass surgery several years previously. Prior to admission, his dialysis history was relatively uneventful. He attended regularly, and was a quiet man who often came to dialysis early to allow himself suffi- cient time to set up his chair with a clean sheet and blanket. He was noted to meet laboratory targets on >90% of occasions without difficulty. On a few occa- sions he had mentioned the onset of fatigue and joint pain to his dialysis team. At the time of admission he Address correspondence to: Sarbjit Vanita Jassal, M.D., University of Toronto, UHN / TRI 8NU-857, 200 Elizabeth St., Toronto, Canada M5G 2C4, or e-mail: vanita.jassal@uhn.ca. Seminars in Dialysis—Vol 25, No 6 (November–December) 2012 pp. 649–656 DOI: 10.1111/sdi.12014 ª 2012 Wiley Periodicals, Inc. LIVING LONGER: OUR CHALLENGES IN GERIATRIC ESRD 649