Peritoneal or hemodialysis for the frail elderly patient, the choice of 2 evils?

Management of older people on dialysis requires focus on the wider aspects of aging as well as dialysis. Almost all frail and older patients receiving dialysis will default to in-center hemodialysis, although the availability of assisted peritoneal dialysis enables dialysis at home. As with any disease management decision, patients approaching end-stage renal disease need all the appropriate facts about their prognosis, the natural history of their disease without dialysis, and the resulting outcomes and complications of the different dialysis modalities. Hemodialysis in the older age group can be complicated by intradialytic hypotension, prolonged time to recovery, and vascular access-related problems. Peritoneal dialysis can be difficult for older patients with impaired physical or cognitive function and can become a considerable burden. Use of incremental dialysis, changes in hemodialysis frequency, and delivery and use of assistance for peritoneal dialysis can ameliorate quality of life for older patients. Understanding each individual's goals of care in the context of his or her life experience is particularly important in the elderly, when overall life expectancy is relatively short, and life experience or quality of life may be the priority. Indeed, some patients select the option of no dialysis or conservative care. With multifaceted assessments of care, physicians should be able to give individual patients the ability to select and continue to make the best decisions for their care.