DISMAL REHABILITATION IN GERIATRIC INNER-CITY HEMODIALYSIS-PATIENTS

Objective.-To assess the extent of functional and vocational rehabilit ation achieved by elderly inner-city patients sustained on maintenance hemodialysis. Design.-Inception cohort study of elderly patients who have end-stage renal disease using a modified Karnofsky rating system. The need for a wheelchair, participation in household activities, and effect of comorbid conditions were noted. Current status was compared with patient's recollection of functional activity level 2 years befo re commencing maintenance hemodialysis. Setting.-Seven outpatient, hos pital-affiliated and private hemodialysis units in Brooklyn, NY. Patie nts.-One hundred four patients aged 65 years or older who were receivi ng maintenance hemodialysis for at least 6 months. Main Outcome Measur es.-A score of 76 or greater on a modified Karnofsky scale indicated i ndependent function at a level that permitted participation in activit ies beyond those mandated by the hemodialysis regimen. A comorbidity s core 6 or greater on a newly constructed index correlated with severe debility. Employment status was also recorded. Results.-Present functi onal activity had deteriorated to a modified Karnofsky score of 66+/-1 2.3 (+/-SD) compared with patients' recollection of a mean score of 84 +/-14.3 (P<.001) 2 years before initiation of hemodialysis. Diabetic p atients had a lower score than nondiabetic patients. The mean comorbid ity index of the entire study group was 7.8+/-2.9 (mean+/-SD). Within the diabetic subset, severe debility constrained 71 patients (68%) to limit all activity to their residence with the exception of travel to and from their dialysis facility. By contrast, 2 years prior to commen cing dialytic therapy, 81 diabetic patients (78%) had interests and ac tivities that took them outside their homes (P<.001). Generalized weak ness was the most common explanation given for the lack of outside act ivity by nine patients (9%) who were wheelchair bound. Erythropoietin, though regularly administered to 87 patients (84%) in the study group , was unsuccessful in raising mean hematocrit reading above 0.28+/-0.0 5 (mean+/-SD). Conclusions.-Maintenance hemodialysis does not return i nner-city elderly patients to their predialysis level of functioning. Few elderly, diabetic hemodialysis patients conduct any substantive po rtion of their lives outside their homes. For nondiabetic patients, th e modified Karnofsky score of whites (70.4+/-11.9) and blacks (66.5+/- 15.3), though low, was equivalent (P<.4).