Patterns and Predictors of Functional Decline after Allogeneic Hematopoietic Cell Transplantation in Older Adults

Abstract

As allogeneic hematopoietic cell transplantation (alloHCT) is increasingly offered to older adults, geriatric assessment (GA) has been identified as a useful tool for predicting outcomes, particularly functional status. However, very few studies have examined the longitudinal change in GA measures in the post-alloHCT period. The objectives of this study were to describe the longitudinal change in GA and quality of life (QoL) measures after alloHCT and to identify predictors of greater functional decline post-transplantation. In this single-center prospective cohort study, patients age ≥50 years scheduled for alloHCT completed a cancer-specific GA and the Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT) survey at baseline prior to alloHCT and then at 3, 6, and 12 months post-transplantation. Changes in GA and QoL measures at each post-transplantation time point (3, 6, and 12 months) compared to baseline were analyzed using paired t-tests. Exploration of potential predictors of greater post-transplantation functional decline, as measured by instrumental activities of daily living (IADL) and the Medical Outcomes Study Physical Health scale (MOS-PH), were examined using linear regression and the chi-square 2-sample test of proportions. Mean functional status generally exhibited a pattern of decline at 3 to 6 months post-alloHCT, with recovery to near baseline by 12 months. Mean mental health and emotional QoL were lowest at baseline and improved at all post-transplantation time points. Differences in baseline clinical characteristics were not associated with any differences in functional trajectories. Differences in baseline GA measures-patient-rated Karnofsky Performance Status, IADL, MOS-PH, Timed-Up-and-Go, Blessed Orientation-Memory-Concentration test, and Mental Health Inventory 5-also did not predict greater functional decline at 3 months. Patients whose IADL was improved or maintained at 3 months generally maintained their functional status at 6 and 12 months. Similarly, most patients who had an IADL decline at 3 months still had a functional decline at 6 months, although a proportion did have functional recovery by 12 months. Compared with patients who had improved/maintained IADL at 3 months, those with a decline in IADL at 3 months were significantly more likely to have persistent functional decline at 6 months (P < .0001) and 12 months (P = .02). In older alloHCT recipients, mean functional status declines short term after alloHCT with the possibility of recovery by 6 to 12 months, whereas mean mental and emotional health improve post-alloHCT. Functional decline at 3 months post-alloHCT is associated with persistent functional decline at 12 months.

Keywords: Allogeneic transplant; Functional status; Geriatric assessment; Older adults.

Figure 1.

Trajectories of mean geriatric assessment measures over time after transplant: (a) instrumental activities of daily living (IADL) score, (b) Medical Outcomes Study-Physical Health (MOS-PH) score, (c) patient-rated Karnofsky Performance Status (KPS), (d) Timed-Up-and-Go (seconds), (e) number of falls in last 6 months, (f) Blessed Orientation-Memory-Concentration test, (g) Mental Health Inventory-5 score, (h) body mass index, (i) Medical Outcomes Study Social Support. Vertical lines indicate the standard error of the measures at a given time point. P-values correspond to comparisons between mean score at a given timepoint with the mean score at baseline; * = p-value <0.05, ** = p-value <0.005. BL=baseline, SE=standard error, p=p-value.

Figure 2.

Trajectories of mean Functional Assessment of Cancer Therapy (FACT) quality of life measures over time after transplant: (a) physical well-being, (b) social well-being, (c) emotional well-being, (d) functional well-being, (e) bone marrow transplant (BMT) subscale. Vertical lines indicate the standard error of the measures at a given time point. P-values correspond to comparisons between mean score at a given timepoint with the mean score at baseline; * = p-value <0.05, ** = p-value <0.005. BL=baseline, SE=standard error, p=p-value.

Figure 3.

Trajectories of mean instrumental activities of daily living (IADL) and Medical Outcomes Study Physical Health (MOS-PH) scores by baseline characteristics, respectively: (a-b) age, (c-d) Hematopoietic cell transplantation comorbidity index (HCT-CI), (e-f) provider-rated Karnofsky Performance Status (KPS), (g-h) transplant intensity, (i-j) diagnosis. Vertical lines indicate the standard error of the measures at a given time point. P-values correspond to comparisons between mean scores between subgroups at each timepoint; * = p-value <0.05, ** = p-value <0.005. AML=acute myeloid leukemia, ALL=acute lymphoblastic leukemia, MDS=myelodysplastic syndrome, MPN=myeloproliferative neoplasm, CMML=chronic myelomonocytic leukemia, CML=chronic myeloid leukemia, NHL=non-Hodgkin lymphoma, HL=Hodgkin lymphoma, MM=multiple myeloma, CLL=chronic lymphocytic leukemia.

Figure 4.

Impact of 3-month post-transplant functional change on longer term functional status. (a) Instrumental activities of daily living (IADL) change from baseline at 6 and 12 months according to whether patients demonstrated improved/maintained IADL scores (imp/main 3m), declined IADL scores (decline 3m), or were missing but alive (missing 3m) at 3 months post-transplant. (b) Medical Outcomes Study Physical Health (MOS-PH) change from baseline at 6 and 12 months according to whether patients demonstrated improved/maintained MOS-PH scores (imp/main 3m), declined MOS-PH scores (decline 3m), or were missing but alive (missing 3m) at 3 months post-transplant.