Functional impairment associated with increased severity of mental health disorders in Latin American chronic hemodialysis patients

Background: End-Stage Kidney Disease (ESKD) and associated complications are related with increased prevalence of psychological disorders. There is a growing trend of elderly and high comorbid individuals beginning chronic Hemodialysis Programs (HD) while there is limited knowledge about the infl uence of functional impairment and comorbidity burden in the prevalence of mental health disorders and life satisfaction on HD population. The purposes of this study were to report the local prevalence of psychological disorders, life satisfaction and self-reported health status as well to describe differences in functional status and comorbidity burden scores between patients with moderate/severe psychological disorders and those none/mild alterations of a Latin American chronic HD cohort. Methods: Transversal uni-center study in 139 Ecuadorian chronic and stable HD patients. Once patients were eligible to participate six tests were applied to explore functional status (Barthel Index and PPS score), depression, anxiety and stress prevalence (DASS-21 scale) comorbidity burden (Charlson Index), self-rated health state (EQ-5D/VAS) and satisfaction with life (SWLS score) Exclusion criteria were: Time in HD less than 6 months, recent hospitalization (less than 3 months) and severe cognitive impairment. Continuous symmetric variables were described as mean ± standard deviation or median and interquartile range if asymmetric. T-test was used for symmetric continuous variables, U-Mann-Whitney if asymmetric and chi-square for qualitative variables. Results: A total of 79 (55%) patients were male. Mean time in HD was 73 ± 47 months, with mean age 56 ± 15,7 years. Prevalence of moderate/severe mental health disorders were: depression (28%), anxiety (37%) and stress (34%). Moderate/severe depressed patients scored signifi catively lower in Barthel Index (p=0.048) and those with moderate/severe stress scored signifi catively lower in Barthel Index (p=0.025) and PPS score (p=0.030). Time in HD > 92 months was signifi catively related with moderate severe/anxiety (0.044). Unsatisfaction with life was found in 20% of patients and it was signifi catively related with lower functional Barthel Index (p=0.017) and PPS score (p=0.041) when compared with those satisfi ed with life. Patients with self-rated health status <70% on EQ-5D VAS scored signifi catively lower in Barthel Index (p=0.022) and PPS score (0.003) vs those with ≥70% score. No differences were found with age, CKD etiology, civil and laboral status. Conclusions: Prevalence of mental health disorders is similar to other series reported. Patients with moderate/severe depression, stress, unsatisfaction with life, and low self-reported health state had worst functional status than those with none/mild alterations. Time in HD over 7.6 years was associated with higher intensity of anxiety. Research Article Functional impairment associated with increased severity of mental health disorders in Latin American chronic hemodialysis patients Santacruz Juan1*, Santacruz Sahel2, Coloma Ghery2, Reinoso Paulo1, Carlotta Sulbarán1, Ana Vásquez1, Paola Arévalo1, Gabriela Santacruz1, Nancy Mancheno1 and Cristóbal Santacruz1 1Nephrology Unit, “Clínica de los Riñones Menydial-Quito”, Quito-Ecuador 2Psychology Unit, “Clínica de los Riñones Menydial-Quito” Quito-Ecuador Received: 30 July, 2021 Accepted: 27 August, 2021 Published: 28 August, 2021 *Corresponding author: Santacruz Juan, Medical Researcher, “Clínica de los Riñones Menydial”, Calle Vozandes N39-130 y Avenida América, CP: 170521, Quito, Ecuador, Tel: +593979037586; E-mail: https://www.peertechzpublications.com


Introduction
Chronic Kidney Disease (CKD) is a growing health care problem with a worldwide estimated prevalence of 29% in adult population and with more than 2 million people diagnosed with End Stage Kidney Disease (ESKD) who are on kidney transplant program and/or in dialysis treatments [1]. ESKD evolution, it´s associated complications (pruritus, anaemia, appetite lost, physical impairment, etc), symptomatic burden, medications with adverse effects as well as dietary and fl uid restrictions may produce sudden and unpleasant changes in patient's lifestyle once they initiate in-center Hemodialysis (HD). These sudden changes accompanied with dependance feelings (to health-workers and/or to HD machines) and uncertainty about the future have been associated with increased prevalence of emotional and psychological disorders in this population [2,3].
According to several studies, ESKD patients have an increased prevalence of mental health disorders when compared with non-ESKD individual. For example, anxiety is 10% more prevalent in ESKD when compared with non-ESKD patients. Series have reported depression, anxiety and stress prevalences of 23%, 37% and 22%, respectively [3,4]. An increased prevalence of mental health disorders and decreased quality of life may worsen the natural course and evolution of ESKD patients by enhancing symptomatic perception, altering therapeutic adherence, and reducing satisfaction with life [4].
Nowadays there is an increase prevalence of elderly individuals with high comorbidity burden beginning dialysis programs with little known about the impact of functional impairment and high comorbid burden in the prevalence of mental health disorders, unsatisfaction with life and selfreported health status on ESKD population. Also, there is a lack of Latin American data reporting the prevalence of these alterations in the region.
The purposes of this study were to report the local prevalence of psychological disorders, life satisfaction and self-reported health status as well to describe differences in functional status and comorbidity burden scores between patients with moderate/severe psychological disorders and those none/mild alterations of a Latin American chronic HD cohort.

Methods
Observational transversal uni-center study in 139 Ecuadorian chronic hemodialysis patients who received HD treatment at "Clínica de los Riñones Menydial" in Quito-Ecuador. Inclusion criteria were time on HD treatment in the studied center for ≥ 6 months, no recent hospitalization (less than 3 months), age ≥ 18 years. Exclusion criteria were severe cognitive impairment, episode of recent hospitalization, age < 18 years old and time of dialysis treatment in study center less than 6 months. Once patients fulfi lled inclusion criteria and accepted to participate in the study six psychological evaluations tests were applied in each studied patient. The different tests were applied by a psychologist professional before dialysis session in a quiet room with no time limit. Patients with visual or auditive impairment were accompanied by the formal caregiver which helped the patients in case of diffi culties for answering the tests due to visual/hearing impairment or if patients couldn´t read or had diffi culties to understand the questions. The duration of test response was from 40-50 min approximately. Instruments applied for screening of mental health disorders, functional status, comorbidity burden, satisfaction with life, and selfrated health state in studied population were the following:

Mental health disorders screening
Depression, anxiety and stress scale score-21 (DASS-21) [5]: Shortest version of "Depression, Anxiety and Stress Scale score" (DASS). It is a short and easy-to-answer self-report instrument composed by 21 questions that evaluate depression, anxiety and stress intensity [6] according to patient´s answer and all items are summed at the end of the test giving a fi nal score which describes the intensity of psychological alteration [6,7]. Depression severity is classifi ed according to the obtained score as: Mild 5-6 points, moderate 7-10 points, severe 11-13 points, and extremely severe ≥14 points. Anxiety intensity is classifi ed with the following score: Mild 4 points, moderate 5-7 points, severe 8-9 points and extremely severe ≥10 points. Finally, stress intensity is classifi ed with the following score: Mild 8-9 points, moderate 10-12 points, severe 13-16 points and extremely severe ≥17 points. The instrument has a reliability of 88% in depression; 79% in anxiety and 83% in stress screening with a full test reliability of 93% [6,7]. an establish diagnosis for each range of score being from 5-9:

Own perception of health status
Visual analogue scale (EQ-5D/VAS) [12]: This is a patient´s self-rated overall health status based on a visual analogue scale (VAS) ranking from 0 to 100, being 0 the worst selfrating health status and 100 the best self-rated health status [13]. This test belongs to the EQ-5D test which is one of the most used generic health-related quality-of-life instruments worldwide. EQ-5D is a standardized generic instrument composed of three components [12,13]. The fi rst component explores the state of health, the second explores a self-rated overall health status using the visual analogue scale and the third component collects demographic information, age, sex, residence, occupation, family status and incomes contributing with general and demographic information of the studied group [14]. Due to its characteristics, the EQ-5D has achieved a great reputation for its simplicity, validity and reliability, geographic spread, high quality control of the assessment protocols and translations [15].  [18]. It is an easily applicable method with a high level of reliability and validity, easy to interpret and to apply. It is used method for measuring physical incapacity in clinical practice as well as in epidemiological investigation and public health, obtaining a reliability of 88% [17,18].

PPS (Palliative performance scale score) [19]:
This instrument is a modifi cation of the Karnofsky Performance Scale. It was fi rst introduced by Anderson and Downing in 1996 as a new tool for measurement of performance status in palliative care [20]. Its indicators are based on the performance status of the patient and has been used as prognostic tool, disease progression monitoring and in health care planning and administration. This a valuable clinical assessment tool in palliative care and many of other specialties have already incorporated PPS as standard tool in their practice [20].
The test explores fi ve categories: Mobilization, evidence of disease, self-care, food intake, and level of consciousness.
The score ranges from 0 to 100 in an interval of ten points according to the observer fi ndings in each category. Each category contains 10 different scenarios with its respective score and the fi nal score is obtained by selecting the scenario that best fi ts to patient´s clinical and functional situation. It has shown a reliability around 96% [21].

Comorbidity burden
Charlson Index [22]: It was created with the objective of developing a prognostic instrument for comorbidities that, individually or combined, could affect the risk of short-term mortality [23]. Charlson comorbidity index is assessed based on the age and other 19 medical conditions which are cataloged into four groups according to the survival impact assigned to each disease, with a minimum score of 0 and maximum score of 37 [23,24]. These conditions can be obtained through clinical records, medical-administrated databases, and interviews.
The total score is the sum of all clinical entities of the patient resulting in 10-year survival probability with an acceptable interobserver reliability of 95% [23,24].

Statistical analysis
Continuous symmetric variables were described as mean Once instruments were applied to studied population, they were categorized according to the score obtained in each test as follows. For DASS-21 scale subjects who obtained a score ≤ 6 points in depression scale were considered not depressed while subjects with score ≥ 7 were considered depressed. For anxiety scale, subjects who obtained a score ≤ 4 were considered without anxiety and those with score ≥5 were anxious. Finally, in stress scale, subjects with a score ≤ 9 were considered Citation: Santacruz  not stressed while those with score ≥ 10 were considered as stressed patients.
On SWLS test for satisfaction with life screening subjects who obtained a score ≥ 20 points were catalogued as "satisfi ed patients" and were compared for further analysis with patients who obtained scores <20 which were considered as "unsatisfi ed patients".
On EQ/5D-VAS, used as a patient´s self-rated health status, patients were divided in four groups according to self-rated score obtained. Patients with a self-rated score >80 were considered with good self-rated health, those with 60-79 were considered with mild self-rated health impairment, those with 30-59 were considered with moderate self-rated health impairment, those with 0-29 were considered with severe self-rated health impairment. For statistical analysis patients were divided in two groups according to score obtained, those with score <70% were considered with impaired self-rated health state and those with score ≥ 70% were considered with good self-rated health state.

Results
A total 143 chronic hemodialysis patients were receiving treatment in study center and were initially considered for study. Four patients were excluded for the following reasons: One had severe cognitive impairment and three had received dialysis treatment for less than 6 months in the center of study.
Finally, 139 patients fulfi lled inclusion criteria and participated in the study.
There was a male predominance in population studied (55%), a third of patients were single and more than a half were married (52%). A third of studied population completed high-school education (32%). Psychotropics, antidepressants, benzodiazepines and antipsychotics prescription prevalence was 4% for each one of them. A quarter of patients were unemployed, 40% of patients had a formal job, 12% had visited a mental health professional previously with 7% who had visited a psychiatrist and 5% to a psychologist. Table 1  Time in HD treatment was signifi catively related with moderate/severe anxiety prevalence (p=0.044), these differences were observed more signifi catively in patients with more than 92 months in HD treatment. Time in HD was not signifi cative related with prevalence of moderate/ severe depression (p=0,90), moderate/severe stress (p=0.54) unsatisfaction with life (p=0.21) and overall health status selfrating scale score (p=0.26).
Comorbidity, measured by modifi ed Charlson Index score, was not signifi cative related with prevalence of moderate/ severe depression (p=0.72), moderate/severe anxiety (p=0.10),  Several studies have demonstrated similar prevalence of anxiety and depression in chronic dialysis population as the ones showed in our study [25][26][27]. These studies have also shown that stress prevalence was lower (20%-25%) than the one found in our study where it was the second most prevalent mental health alteration (34%).   infl uence in quality of life and early mortality on HD patients [25][26][27][28][29].

Discussion
Our study shows that there is a signifi cative link between a higher moderate/severe anxiety prevalence in patients with a prolonged time in dialysis (over 7.6 years). Previous series haven´t found any relation between time in dialysis treatment and an increased prevalence of anxiety [3,4]. This difference observed in our study could be explained by the fact that local transplant programs are neither effective nor active, resulting in prolonged stays on dialysis treatment whereas previous studies were developed in Spain [3,4], country known for their effective and very active transplant program that avoid such prolonged stays on dialysis treatments [30].
Limitans of the study were a small sample size, only HD population studied, which could compromise external validity, also, COVID-19 pandemic outbreak was another important limitation due to the forced use of personal special equipment (facemasks, face-shields) that negatively committed the communication with patients. Also, fear of getting infected with COVID-19 disease was another limitation which was caused for the fact of being in a small quiet room for solving the tests causing annoying and disturbance to studied patients.
One more limitation was the lack of time for test response due to the rush of patients to begin dialysis session.
The strengths of the study were a homogenous population studied, the use of validated instruments to measure the pathologies analyzed and the fact that functional impairment was objectively measured and compared between pathological and non-pathological groups to analyze the presence of signifi cative differences.
To conclude, this study demonstrates a clear relationship between a decreased functional status and a higher prevalence of moderate/severe stress and depression, unsatisfaction with life and low self-reported health-state as well as an increased prevalence of moderate/severe anxiety in patients with HD stays longer than 7.6 years. We consider that specifi c programs of premature identifi cation and effective intervention in this rising elderly, functional impaired and high comorbid chronic dialysis population, might decrease the severity of mental health disorders, unsatisfaction with life, and low selfreported health-state. We suggest that psychological services should provide effective tools to deal with stressful situations to hemodialysis patients. More research studies are needed in this topic.