By Peter Laird, MD
As a child, I found out early on that sports requiring agility and dexterity were not my forte, but I did do well in areas of strength and stamina. I did acquire a degree of proficiency as a skier by my mid thirties, but probably not even to the degree that my older brother acquired by his teen years. I had excellent sprinting speed at 10.7 seconds in the hundred and I could run two miles in less than 11 minutes. Neither by themselves were world class by any means, but together, my best sport should have been soccer which requires a unique combination of speed and endurance, if only I didn’t trip over my own feet.
Fortunately, I found other hobbies to excel outside of the sports world and became well versed in several. Renal disease did affect my abilities to overcome fatigue in the practice of medicine requiring me to walk away from in-patient medicine two years before starting on dialysis. Passing the age of 50 has not done wonders for my memory as well, but the added burden of renal disease and dialysis gives me a noted difficulty at times recalling words that I should be able to recall easily. Several studies on dialysis patients have noted this very finding as the most predominate cognitive impairment of renal disease in dialysis patients. However, I can still walk, talk and chew gum so to speak as well as I have always accomplished those tasks, just don’t ask me to do all of that and control a soccer ball as well.
The issue of cognitive impairment among dialysis patients is not often discussed. Gary Peterson of RenalWeb posted a link to a recent article discussing the high prevalence of cognitive impairment among dialysis patients. Interestingly, prior studies have shown dramatic reversals of cognitive impairment after renal transplant and anecdotally my own nephrologist enjoys telling the story of one of his elderly patients with symptoms of dementia on conventional in-center dialysis who blossomed again after going home on daily dialysis. Nevertheless, the author of the paper noted above made a dramatic statement that caught my eye:
High Prevalence of Cognitive Impairment Seen in CKD Patients
“If one of your patients has moderate chronic kidney disease – an estimated GFR of less than 50 mL/min per 1.73 m2 – they should be screened for cognitive impairment, because they probably can’t take their medications on their own, and their judgment is probably impaired when it comes to making a decision about starting dialysis,” Dr. Murray noted.
I readily understand the personal battle of maintaining cognitive function as part of my own renal rehabilitation, yet the statement that broadly paints all CKD patients with a GFR less than 50 in my opinion may be taking too broad a swath at an agreed upon common problem; but if extrapolated to the dozens of quite elderly US Supreme Court justices in the last century, if we did have access to their health care status, I suspect that before retirement and while still active on the bench, many of these justices had GFR’s less than 50 by virtue of age alone in many cases, yet did some of their most treasured verdicts in that time frame as well.
Causally implying severe impairment based only on a determination of CKD stage 3 or even stage 4 alone should not imply severe cognitive impairment leading to an essentially incompetent patient and loss of autonomy. If applied to the general CKD 3, 4 or 5 patient population, it is frightening to consider how such an approach and assumption of incompetence could lead to more examples of deferring patient autonomy for a paternalistic approach. The majority of patients already on dialysis sitting next to me over the years were bright, alert and in full control of their faculties and quite capable of making true informed consent over their treatment options.
I would hope that the call for awareness of how common cognitive impairment actually is in the above article does not instead lead to inappropriate judgements against patients prematurely without individual assessments for cognitive impairment. After all, just ask my wife, I still walk, talk and chew gum as well as I ever did, just don’t ask my brother how well I did that growing up.