The assessment of cognitive function in older adult patients with chronic kidney disease: an integrative review

  • Mary Hannan
  • Alana Steffen
  • Lauretta Quinn
  • Eileen G. Collins
  • Shane A. Phillips
  • Ulf G. Bronas



Chronic kidney disease (CKD) is a common chronic condition in older adults that is associated with cognitive decline. However, the exact prevalence of cognitive impairment in older adults with CKD is unclear likely due to the variety of methods utilized to assess cognitive function. The purpose of this integrative review is to determine how cognitive function is most frequently assessed in older adult patients with CKD.


Five electronic databases were searched to explore relevant literature related to cognitive function assessment in older adult patients with CKD. Inclusion and exclusion criteria were created to focus the search to the assessment of cognitive function with standardized cognitive tests in older adults with CKD, not on renal replacement therapy.


Through the search methods, 36 articles were found that fulfilled the purpose of the review. There were 36 different types of cognitive tests utilized in the included articles, with each study utilizing between one and 12 tests. The most commonly utilized cognitive test was the Mini Mental State Exam (MMSE), followed by tests of digit symbol substitution and verbal fluency. The most commonly assessed aspect of cognitive function was global cognition.


The assessment of cognitive function in older adults with CKD with standardized tests is completed in various ways. Unfortunately, the common methods of assessment of cognitive function may not be fully examining the domains of impairment commonly found in older adults with CKD. Further research is needed to identify the ideal cognitive test to best assess older adults with CKD for cognitive impairment.


Older adult Cognitive impairment Kidney disease 



Mary Hannan is a Robert Wood Johnson Foundation Future of Nursing Scholar. Ulf G. Bronas is supported by the Midwest Roybal Center for Health Promotion and Translation.


This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Compliance with ethical standards

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ethical statement

Human subjects were not utilized in this research. For this type of study formal consent is not required. This article does not contain any studies with human participants or animals performed by any of the authors.

Supplementary material

40620_2018_494_MOESM1_ESM.xlsx (19 kb)
Supplementary material 1 (XLSX 19 KB)


  1. 1.
    Centers for Disease Control and Prevention (CDC) (2016) Chronic kidney disease (CKD) surveillance project. Accessed 30 Sep 2016
  2. 2.
    Stevens LA, Viswanathan G, Weiner DE (2010) Chronic kidney disease and end-stage renal disease in the elderly population: current prevalence, future projections, and clinical significance. Adv Chronic Kidney D 17(4):293–301CrossRefGoogle Scholar
  3. 3.
    Tamura MK, Larive B, Unruh ML et al (2010) Prevalence and correlates of cognitive impairment in hemodialysis patients: the frequent hemodialysis network trials. Clin J Am Soc Nephrol 5(8):1429–1438CrossRefPubMedCentralGoogle Scholar
  4. 4.
    Helmer C, Stengel B, Metzger M et al (2011) Chronic kidney disease, cognitive decline, and incident dementia: the 3C study. Neurology 77(23):2043–2051CrossRefPubMedGoogle Scholar
  5. 5.
    Bronas UG, Puzantian H, Hannan M (2017) Cognitive impairment in chronic kidney disease: vascular milieu and the potential therapeutic role of exercise. Biomed Res Int. CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Murray A, Tupper DE, Knopman DS et al (2006) Cognitive impairment in hemodialysis patients is common. Neurology 67(2):216–223CrossRefPubMedGoogle Scholar
  7. 7.
    Tamura MK, Yaffe K, Hsu CY et al (2016) Cognitive impairment and progression of CKD. Am J Kidney Dis 68(1):77–83CrossRefPubMedCentralGoogle Scholar
  8. 8.
    Kurella Tamura M (2008) Kidney function and cognitive impairment in US adults: the reasons for geographic and racial differences in stroke (REGARDS) study. Am J Kidney Dis 52(2):227–234CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Kurella M, Chertow GM, Luan J, Yaffe K (2004) Cognitive impairment in chronic kidney disease. J Am Geriatr Soc 52(11):1863–1869CrossRefPubMedGoogle Scholar
  10. 10.
    Etgen T, Chonchol M, Förstl H, Sander D (2012) Chronic kidney disease and cognitive impairment: a systematic review and meta-analysis. Am J Nephrol 35(5):474–482CrossRefPubMedGoogle Scholar
  11. 11.
    O’Lone E, Connors M, Masson P et al (2016) Cognition in people with end-stage kidney disease treated With hemodialysis: a systematic review and meta-analysis. Am J Kidney Dis 67(6):925–935CrossRefPubMedGoogle Scholar
  12. 12.
    Weng S-C, Shu K-H, Tang Y-J et al (2012) Progression of cognitive dysfunction in elderly chronic kidney disease patients in a veteran’s institution in central Taiwan: a 3-year longitudinal study. Intern Med 51(1):29–35CrossRefPubMedGoogle Scholar
  13. 13.
    Seliger SL, Siscovick DS, Stehman-Breen CO et al (2004) Moderate renal impairment and risk of dementia among older adults: the Cardiovascular Health Cognition Study. J Am Soc Nephrol 15(7):1904–1911CrossRefPubMedGoogle Scholar
  14. 14.
    Madero M, Gul A, Sarnak MJ (2008) Cognitive function in chronic kidney disease. Semin Dial 21(1):29–37CrossRefPubMedGoogle Scholar
  15. 15.
    Murray A (2010) Cognitive impairment in CKD: no longer an occult burden. Am J Kidney Dis 56(4):615–618CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Molnar MZ, Sumida K, Gaipov A et al (2017) Pre-ESRD dementia and post-ESRD mortality in a large cohort of incident dialysis patients. Dement Geriatr Cogn Disord 43(5–6):281–293CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    American Psychiatric Association (2017) Diagnostic and statistical manual of mental disorders, 5th edn. DSM Library, Washington, DCGoogle Scholar
  18. 18.
    Sachdev PS, Blacker D, Blazer DG et al (2014) Classifying neurocognitive disorders: the DSM-5 approach. Nat Rev Neurol 10(11):634CrossRefPubMedGoogle Scholar
  19. 19.
    Petersen RC, Smith GE, Waring SC, Ivnik RJ, Tangalos EG, Kokmen E (1999) Mild cognitive impairment: clinical characterization and outcome. Arch Neurol 56(3):303–308CrossRefPubMedGoogle Scholar
  20. 20.
    Lindeboom J, Weinstein H (2004) Neuropsychology of cognitive ageing, minimal cognitive impairment, Alzheimer’s disease, and vascular cognitive impairment. Eur Pharmacol 490(1):83–86CrossRefGoogle Scholar
  21. 21.
    Roberts RO, Knopman DS, Mielke MM et al (2014) Higher risk of progression to dementia in mild cognitive impairment cases who revert to normal. Neurology 82(4):317–325CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    National Kidney Foundation (NKF) (2002) KDOQI guideline 6—association of level of GFR with complications adults. Accessed 24 Aug 2017
  23. 23.
    Bugnicourt J-M, Godefroy O, Chillon J-M, Choukroun G, Massy ZA (2013) Cognitive disorders and dementia in CKD: the neglected kidney–brain axis. J Am Soc Nephrol 24(3):353–363CrossRefPubMedGoogle Scholar
  24. 24.
    Whittemore R, Knafl K (2005) The integrative review: updated methodology. J Adv Nurs 52(5):546–553CrossRefPubMedGoogle Scholar
  25. 25.
    Darsie B, Shlipak MG, Sarnak MJ, Katz R, Fitzpatrick AL, Odden MC (2014) Kidney function and cognitive health in older adults: the Cardiovascular Health Study. Am J Epidemiol 180(1):68–75CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    United States Renal Data System (USRDS) (2005) USRDS 2005 annual data report: atlas of end-stage renal disease in the United States. Accessed 2 Nov 2017
  27. 27.
    World Health Organization (2016) Proposed working definition of an older person in Africa for the MDS Project. Accessed 30 Oct 2017
  28. 28.
    Office of Disease Prevention and Health Promotion (2017) Older adults: healthy people 2020. Accessed 30 Oct 2017
  29. 29.
    Kurella Tamura M, Vittinghoff E, Hsu C-y et al (2017) Loss of executive function after dialysis initiation in adults with chronic kidney disease. Kidney Int 91(4):948–953CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Murray A (2008) Cognitive impairment in the aging dialysis and chronic kidney disease populations: an occult burden. Adv Chronic Kidney Dis 15(2):123–132CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Gupta A, Mahnken JD, Johnson DK et al (2017) Prevalence and correlates of cognitive impairment in kidney transplant recipients. BMC Nephrol 18(1):158CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Moher D, Tetlzlaff J, Altman DG, The Prisma Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6(7):e1000097CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Antunes JPV, Bulhões C, Fonte P, Abreu MJ, Oliveira R (2015) Renal function and cognitive dysfunction: cross-sectional study of users enrolled at Ponte-Family Health Unit. J Bras Nefrol 37(1):79–90CrossRefPubMedGoogle Scholar
  34. 34.
    Buchman AS, Tanne D, Boyle PA, Shah RC, Leurgans SE, Bennett DA (2009) Kidney function is associated with the rate of cognitive decline in the elderly. Neurology 73(12):920–927CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Elias MF, Elias PK, Seliger SL, Narsipur SS, Dore GA, Robbins MA (2009) Chronic kidney disease, creatinine and cognitive functioning. Nephrol Dial Transpl 24(8):2446–2452CrossRefGoogle Scholar
  36. 36.
    Etgen T, Sander D, Chonchol M et al (2009) Chronic kidney disease is associated with incident cognitive impairment in the elderly: the INVADE study. Nephrol Dial Transpl 24(10):3144–3150CrossRefGoogle Scholar
  37. 37.
    Foster R, Walker S, Brar R et al (2016) Cognitive impairment in advanced chronic kidney disease: the Canadian frailty observation and interventions trial. Am J Nephrol 44(6):473–480CrossRefPubMedGoogle Scholar
  38. 38.
    Jovanovich AJ, Chonchol M, Brady CB et al (2014) 25-vitamin D, 1,25-vitamin D, parathyroid hormone, fibroblast growth factor-23 and cognitive function in men with advanced CKD: a veteran population. Clin Nephrol 82(5):S1–303PubMedGoogle Scholar
  39. 39.
    Kurella M, Yaffe K, Shlipak MG, Wenger NK, Chertow GM (2005) Chronic kidney disease and cognitive impairment in menopausal women. Am J Kidney Dis 45(1):66–76CrossRefPubMedGoogle Scholar
  40. 40.
    Kurella M, Chertow GM, Fried LF et al (2005) Chronic kidney disease and cognitive impairment in the elderly: the health, aging, and body composition study. J Am Soc Nephrol 16(7):2127–2133CrossRefPubMedGoogle Scholar
  41. 41.
    Lai S, Mecarelli O, Pulitano P et al (2016) Neurological, psychological, and cognitive disorders in patients with chronic kidney disease on conservative and replacement therapy. Medicine 95(48):e5191CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Lee JJ, Chin HJ, Byun MS et al (2011) Impaired frontal executive function and predialytic chronic kidney disease. J Am Geriatr Soc 59(9):1628–1635CrossRefPubMedGoogle Scholar
  43. 43.
    Lee S, Shimada H, Park H et al (2015) The association between kidney function and cognitive decline in community-dwelling, elderly Japanese people. J Am Med Dir Assoc 16(4):349.e341CrossRefGoogle Scholar
  44. 44.
    Lin C-Y, Lin J-W, Lin L-Y, Kuo H-K (2009) Chronic kidney disease, atherosclerosis, and cognitive and physical function in the geriatric group of the National Health and Nutrition Survey 1999–2002. Atherosclerosis 202(1):312–319CrossRefPubMedGoogle Scholar
  45. 45.
    Murray AM, Bell EJ, Tupper DE et al (2016) The brain in kidney disease (BRINK) cohort study: design and baseline cognitive function. Am J Kidney Dis 67(4):593–600CrossRefPubMedGoogle Scholar
  46. 46.
    Rodriguez Villarreal I, Ortega O, Hinostroza J et al (2014) Geriatric assessment for therapeutic decision-making regarding renal replacement in elderly patients with advanced chronic kidney disease. Nephron Clin Pract 128(1–2):73–78CrossRefPubMedGoogle Scholar
  47. 47.
    Romijn MDM, van Marum RJ, Emmelot-Vonk MH, Verhaar HJJ, Koek HL (2015) Mild chronic kidney disease is associated with cognitive function in patients presenting at a memory clinic: association between chronic kidney disease and cognitive function. Int J Geriatr Psychiatry 30(7):758–765CrossRefPubMedGoogle Scholar
  48. 48.
    Sasaki Y, Marioni R, Kasai M, Ishii H, Yamaguchi S, Meguro K (2011) Chronic kidney disease: a risk factor for dementia onset: a population-based study. The Osaki-Tajiri project. J Am Geriatr Soc 59(7):1175–1181CrossRefPubMedGoogle Scholar
  49. 49.
    Slinin Y, Osteoporotic Fractures in Men Study G (2008) Kidney function and cognitive performance and decline in older men. J Am Geriatr Soc 56(11):2082–2088CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Srivanitchapoom P, Senanarong V (2013) Estimated creatinine clearance and cognitive impairment in Thai older adults: a pilot study from the dementia and disability project in Thailand. J Med Assoc Thai 96(Suppl 2):S47PubMedGoogle Scholar
  51. 51.
    Umemura T, Kawamura T, Umegaki H et al (2013) Association of chronic kidney disease and cerebral small vessel disease with cognitive impairment in elderly patients with type 2 diabetes. Dement Geriatr Cogn Dis Extra 3(1):212–222CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Wang H, Liu T, Cai Y-y, Jiang H, Liu H-x, Lin C (2016) Kidney function and cognitive impairment in people aged 80 years and over with untreated hypertension: a cross-sectional survey. Kidney Blood Press Res 41(1):70–77CrossRefPubMedGoogle Scholar
  53. 53.
    Khatri M, Nickolas TL, Moon YP et al (2009) CKD associates with cognitive decline. J Am Soc Nephrol 20(11):2427–2432CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Zammit AR, Katz MJ, Lai JY, Zimmerman ME, Bitzer M, Lipton RB (2015) Association between renal function and cognitive ability domains in the Einstein aging study: a cross-sectional analysis. J Gerontol A Biol Sci 70(6):764–770CrossRefGoogle Scholar
  55. 55.
    Post JB, Jegede AB, Morin K, Spungen AM, Langhoff E, Sano M (2010) Cognitive profile of chronic kidney disease and hemodialysis patients without dementia. Nephron Clin Pract 116(3):c247–c255CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Corrao S, Argano C, Nobili A et al (2015) Brain and kidney, victims of atrial microembolism in elderly hospitalized patients? Data from the REPOSI study. Eur J Int Med 26(4):243–249CrossRefGoogle Scholar
  57. 57.
    Rodríguez-Angarita CE, Sanabria-Arenas RM, Vargas-Jaramillo JD, Ronderos-Botero I (2016) Cognitive impairment and depression in a population of patients with chronic kidney disease in Colombia: a prevalence study. Can J Kidney Health Dis 3(1):26PubMedPubMedCentralGoogle Scholar
  58. 58.
    Feng L, Yap KB, Ng TP (2013) Depressive symptoms in older adults with chronic kidney disease: mortality, quality of life outcomes, and correlates. Am J Geriatr Psychiatry 21(6):570CrossRefPubMedGoogle Scholar
  59. 59.
    Pulignano G, Del Sindaco D, Di Lenarda A et al (2014) Chronic renal dysfunction and anaemia are associated with cognitive impairment in older patients with heart failure. J Cardiovasc Med (Hagerstown) 15(6):481–490CrossRefGoogle Scholar
  60. 60.
    Auriel E, Kliper E, Shenhar-Tsarfaty S et al (2016) Impaired renal function is associated with brain atrophy and poststroke cognitive decline. Neurology 86(21):1996–2005CrossRefPubMedGoogle Scholar
  61. 61.
    Kuriyama N, Mizuno T, Ohshima Y et al (2013) Intracranial deep white matter lesions (DWLs) are associated with chronic kidney disease (CKD) and cognitive impairment: a 5-year follow-up magnetic resonance imaging (MRI) study. Arch Gerontol Geriatr 56(1):55–60CrossRefPubMedGoogle Scholar
  62. 62.
    Hobson P, Rohoma Kamel H, Wong Stephen P, Kumwenda Mick J (2016) The utility of the Mini-Addenbrooke’s Cognitive Examination as a screen for cognitive impairment in elderly patients with chronic kidney disease and diabetes. Dement Geriatr Cogn Dis Extra 6(3):541–548CrossRefPubMedPubMedCentralGoogle Scholar
  63. 63.
    Afsar B, Elsurer R, Covic A, Johnson RJ, Kanbay M (2011) Relationship between uric acid and subtle cognitive dysfunction in chronic kidney disease. Am J Nephrol 34(1):49–54CrossRefPubMedPubMedCentralGoogle Scholar
  64. 64.
    Amano C, Ito T, Egawa M et al (2013) Effects of different administration protocols on the plasma concentration of donepezil hydrochloride in dementia patients with stage 5 chronic kidney disease. Nephron Extra 3(1):59–65CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Chen Y-C, Weng S-C, Liu J-S, Chuang H-L, Hsu C-C, Tarng D-C (2017) Severe decline of estimated glomerular filtration rate associates with progressive cognitive deterioration in the elderly: a community-based cohort study. Sci Rep 7:42690CrossRefPubMedPubMedCentralGoogle Scholar
  66. 66.
    Iyasere O, Okai D, Brown E (2017) Cognitive function and advanced kidney disease: longitudinal trends and impact on decision-making. Clin Kid J 10(1):89–94Google Scholar
  67. 67.
    Olsen J, Baisch MJ (2014) An integrative review of information systems and terminologies used in local health departments. J Am Med Inform Assoc 21(e1):e20–e27CrossRefPubMedGoogle Scholar
  68. 68.
    Kurella Tamura M, Yaffe K (2011) Dementia and cognitive impairment in ESRD: diagnostic and therapeutic strategies. Kidney Int 79(1):14–22CrossRefPubMedGoogle Scholar
  69. 69.
    Schneider SM, Kielstein JT, Braverman J, Novak M (2015) Cognitive function in patients with chronic kidney disease: challenges in neuropsychological assessments. Semin Nephrol 35(4):304CrossRefPubMedGoogle Scholar
  70. 70.
    Weiner DE, Gaussoin SA, Nord J et al (2017) Cognitive function and kidney disease: baseline data from the systolic blood pressure intervention trial (SPRINT). Am J Kidney Dis 70(3):357–367CrossRefPubMedPubMedCentralGoogle Scholar
  71. 71.
    Yaffe K, Chronic Renal Insufficiency Cohort I (2010) Chronic kidney disease and cognitive function in older adults: findings from the chronic renal insufficiency cohort cognitive study. J Am Geriatr Soc 58(2):338–345CrossRefPubMedPubMedCentralGoogle Scholar
  72. 72.
    Nasreddine ZS, Phillips NA, Bédirian V et al (2005) The montreal cognitive assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 53(4):695–699CrossRefPubMedGoogle Scholar
  73. 73.
    Hoyer WJ, Stawski RS, Wasylyshyn C, Verhaeghen P (2004) Adult age and digit symbol substitution performance: a meta-analysis. Psychol Aging 19(1):211–214CrossRefPubMedGoogle Scholar
  74. 74.
    Stephens R, Kaufman A (2009) The role of long-term memory in digit-symbol test performance in young and older adults. Neuropsychol Dev Cogn 16(2):219CrossRefGoogle Scholar
  75. 75.
    Wechsler D (1958) The measurement and appraisal of adult intelligence, 4th edn. Williams & Wilkins, BaltimoreCrossRefGoogle Scholar
  76. 76.
    Tombaugh TN, Kozak J, Rees L (1999) Normative data stratified by age and education for two measures of verbal fluency: FAS and animal naming. Arch Clin Neuropsychol 14(2):167–177PubMedGoogle Scholar
  77. 77.
    Neumann D, Robinski M, Mau W, Girndt M (2017) Cognitive testing in patients with CKD: the problem of missing cases. Clin J Am Soc Nephrol 12(3):391–398CrossRefPubMedPubMedCentralGoogle Scholar
  78. 78.
    Conn VS, Valentine JC, Cooper HM, Rantz MJ (2003) Grey literature in meta-analyses. Nurs Res 52(4):256–261CrossRefPubMedGoogle Scholar

Copyright information

© Italian Society of Nephrology 2018

Authors and Affiliations

  1. 1.Department of Biobehavioral Health Science, College of NursingUniversity of Illinois at ChicagoChicagoUSA
  2. 2.Department of Health Systems Science, College of NursingUniversity of Illinois at ChicagoChicagoUSA
  3. 3.Department of Physical Therapy, College of Allied Health ScienceUniversity of Illinois at ChicagoChicagoUSA

Personalised recommendations