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Published on: October 2, 2020
Cognitive Decline and Its Risk Factors in Prevalent Hemodialysis Patients
David A Drew1, Daniel E Weiner1, Hocine Tighiouart2
1Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, MA.
Insights
Patients on hemodialysis experience significant cognitive decline, especially in executive function. Older age is the primary risk factor, highlighting the need for clinical management strategies to support cognitive health in this population.
Area of Science:
- Nephrology
- Neuroscience
- Gerontology
Background:
- Cognitive impairment is a frequent complication in patients undergoing hemodialysis.
- The long-term cognitive trajectory and associated risk factors in this patient group are not well understood.
Purpose of the Study:
- To investigate the longitudinal changes in cognitive function among prevalent hemodialysis patients.
- To identify risk factors associated with cognitive decline in this population.
Main Methods:
- A longitudinal cohort study involving 314 prevalent hemodialysis patients.
- Cognitive function was assessed using a comprehensive neurocognitive battery measuring memory and executive function.
- Statistical analysis employed linear mixed models and joint models to account for competing risks.
Main Results:
- A decline in executive function ( -0.09 SD/year) and a slight improvement in memory (0.05 SD/year) were observed.
- The Mini-Mental State Examination score also showed a significant yearly decline.
- Older age was the sole significant predictor of accelerated executive function decline.
Conclusions:
- Prevalent hemodialysis patients exhibit notable cognitive decline, particularly in executive function.
- Older age is a key risk factor for cognitive decline, impacting patient management.
- Further research is needed to develop interventions aimed at preserving or enhancing cognitive function in hemodialysis patients.
Background:
Cognitive impairment is common in patients treated with hemodialysis. The trajectory of cognitive function and risk factors for cognitive decline remain uncertain in this population.
Study Design:
Longitudinal cohort.
Setting & Participants:
314 prevalent hemodialysis patients.
Predictors:
Age, sex, race, education level, hemodialysis vintage, cause of end-stage renal disease, and baseline history of cardiovascular disease.
Outcomes:
Cognitive function as determined by a comprehensive neurocognitive battery, administered at baseline and yearly when possible. Individual cognitive test results were reduced into 2 domain scores using principal components analysis, representing memory and executive function, which were used as our coprimary outcomes and by definition have a mean of zero and SD of 1.
Results:
Mean age was 63 years; 54% were men, 22% were black, and 90% had at least a high school education. During a median follow-up of 2.1 (IQR, 0.9-4.2) years, 196 had at least 1 follow-up test, 156 died, and 43 received a kidney transplant. Linear mixed models and joint models, which accounted for competing risks from death, dropout, or kidney transplantation, showed nearly identical results. The joint model demonstrated a decline in executive function (-0.09 [95% CI, -0.13 to -0.05] SD per year), whereas memory improved slightly (0.05 [95% CI, 0.02 to 0.08] SD per year). A significant yearly decline was also seen in the Mini-Mental State Examination score (median change, -0.41; 95% CI, -0.57 to -0.25). Older age was the only significant risk factor for steeper executive function decline (-0.04 [95% CI, -0.06 to -0.02] SD steeper annual decline for each 10 years of age).
Limitations:
Prevalent hemodialysis patients only, limited follow-up testing due to high mortality rate, and exclusion of participants with severe cognitive deficits or dementia.
Conclusions:
Prevalent hemodialysis patients demonstrate significant cognitive decline, particularly within tests of executive function. Older age was the only statistically significant risk factor for steeper cognitive decline, which may have important clinical consequences for patient management and education. Future studies should evaluate strategies to maintain or improve cognitive function.
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