Serial comprehensive geriatric and quality of life assessments in adults age ≥ 50 years undergoing autologous hematopoietic cell transplantation

Assessment of Mobility Trajectories Using Wearable Inertial Sensors During Autologous Hematopoietic Cell Transplant

OBJECTIVE

This study aimed to characterize mobility patterns using wearable inertial sensors and serial assessment across autologous hematopoietic cell transplant (autoHCT) and investigate the relation between mobility and perceived function in patients with hematologic cancer.

DESIGN

Prospective longitudinal study.

SETTING

Hospital adult transplant clinic followed by discharge.

PARTICIPANTS

78 patients with hematological cancer receiving autoHCT.

MAIN OUTCOME MEASURES

Mobility was measured across 3 clinical phases (pretransplant, pre-engraftment, and post-engraftment) in using inertial sensors worn during prescribed performance tests in the hospital. Perceived function was assessed using validated provider-reported (Eastern Cooperative Oncology Group [ECOG] Performance Status Scale) and patient-reported [European Organization for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC QLQ-C30]) measures. Trajectories of 5 selected mobility characteristics (turn duration, gait speed, stride time variability, double support time, and heel strike angle) across the clinical phases were also evaluated using piecewise linear mixed-effects models.

RESULTS

Using Principal Components Analysis, 4 mobility patterns were identified pretransplant: Gait Limitation, Sagittal Sway, Coronal Sway, and Balance Control. Gait Limitation measured pretransplant was significantly inversely associated with perceived function reported by the provider- (β = -0.11; 95% CI: -0.19, -0.02) and patient- (β = -4.85; 95% CI: -7.72, -1.99) post-engraftment in age-adjusted linear regression models. Mobility characteristics demonstrated immediate declines early pre-engraftment with stabilization by late pre-engraftment.

CONCLUSION

Patients with hematological cancer experiencing gait limitations pretransplant are likely to have worse perceived function post-engraftment. Mobility declines in early phases post-transplant and may not fully recover, indicating an opportunity for timely rehabilitation referrals. Wearable inertial sensors can be used to identify early mobility problems and patients who may be at risk for future functional decline who may be candidates for early physical rehabilitation.

Potentially inappropriate medications in geriatric blood or marrow transplantation (BMT) survivors: A BMT Survivor Study report

BACKGROUND

Blood or marrow transplantation (BMT) is increasingly offered to older individuals with hematologic malignancies. The high prevalence of chronic health conditions in such individuals necessitates use of multiple medications. Beers Criteria represent a list of potentially inappropriate medications (PIMs) shown to increase the risk of health problems in the elderly. We sought to determine the prevalence and predictors of PIM use in older BMT survivors and identify associations with health problems.

METHODS

Study participants were drawn from the BMT Survivor Study, a cohort study of patients transplanted at three US transplant centers between 1974 and 2014 and surviving ≥2 years. For this report, the survivors were aged ≥65 years. Siblings served as a comparison group. Participants self-reported sociodemographics, chronic health conditions, and medication use. Logistic regression analyses identified predictors of PIM use and associations with health problems.

RESULTS

Overall, PIM use was comparable between BMT survivors (49.4%) and siblings (49.3%) (odds ratio [OR] = 0.9; 95% CI, 0.7-1.2); however, BMT survivors were more likely to use >1 PIM (17.4% vs. 12.4%; OR = 1.5; 95% CI, 1.01-2.4) and central nervous system-related PIMs (8.3% vs. 4.3%; OR = 2.18; 95% CI, 1.17-4.09). Predictors of PIM use included presence of severe/life-threatening chronic health conditions (OR = 1.5; 95% CI, 1.1-2.0), and chronic graft versus host disease (OR = 1.7; 95% CI, 1.1-2.7). Survivors taking >1 PIM reported more issues with vertigo (OR = 2.3; 95% CI, 1.1-4.7), balance (OR = 2.6; 95% CI, 1.7-4.1), faintness/dizziness (OR = 2.8; 95% CI, 1.8-4.6), and personal care (OR = 4.5; 95% CI, 1.4-14.8).

CONCLUSIONS

This study shows the health problems associated with PIM use and identifies vulnerable populations at higher risk for PIM use, providing evidence for caution in using PIMs in high-risk populations.

Using Wearable Inertial Sensors to Assess Mobility of Patients With Hematologic Cancer and Associations With Chemotherapy-Related Symptoms Before Autologous Hematopoietic Stem Cell Transplant: Cross-sectional Study

BACKGROUND

Wearable sensors could be a simple way to quantify and characterize mobility in patients with hematologic cancer scheduled to receive autologous hematopoietic stem cell transplant (autoHSCT) and how they may be related to common treatment-related symptoms and side effects of induction chemotherapy.

OBJECTIVE

We aimed to conduct a cross-sectional study comparing mobility in patients scheduled to receive autoHSCT with that in healthy, age-matched adult controls and determine the relationships between patient mobility and chemotherapy-related symptoms.

METHODS

Patients scheduled to receive autoHSCT (78/156, 50%) and controls (78/156, 50%) completed the prescribed performance tests using wearable inertial sensors to quantify mobility including turning (turn duration and number of steps), gait (gait speed, stride time, stride time variability, double support time, coronal trunk range of motion, heel strike angle, and distance traveled), and balance (coronal sway, coronal range, coronal velocity, coronal centroidal frequency, sagittal sway, sagittal range, sagittal velocity, and sagittal centroidal frequency). Patients completed the validated patient-reported questionnaires to assess symptoms common to chemotherapy: chemotherapy-induced peripheral neuropathy (Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity subscale), nausea and pain (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire), fatigue (Patient-Reported Outcomes Measurement Information System Fatigue Short Form 8a), vertigo (Vertigo Symptom Scale-short form), and depression (Center for Epidemiological Studies-Depression). Paired, 2-sided t tests were used to compare mobility between patients and controls. Stepwise multivariable linear regression models were used to evaluate associations between patient mobility and symptoms.

RESULTS

Patients aged 60.3 (SD 10.3) years had significantly worse turning (turn duration; P<.001), gait (gait speed, stride time, stride time variability, double support time, heel strike angle, stride length, and distance traveled; all P<.001), and balance (coronal sway; P<.001, range; P<.001, velocity; P=.02, and frequency; P=.02; and sagittal range; P=.008) than controls. In patients, high nausea was associated with worse stride time variability (ß=.001; P=.005) and heel strike angle (ß=-.088; P=.02). Pain was associated with worse gait speed (ß=-.003; P=.003), stride time variability (ß=.012; P=.02), stride length (ß=-.002; P=.004), and distance traveled (ß=-.786; P=.005). Nausea and pain explained 17% to 33% and 14% to 36% of gait variance measured in patients, respectively.

CONCLUSIONS

Patients scheduled to receive autoHSCT demonstrated worse mobility in multiple turning, gait, and balance domains compared with controls, potentially related in part to nausea and pain. Wearable inertial sensors used in the clinic setting could provide granular information about mobility before further treatment, which may in turn benefit from rehabilitation or symptom management. Future longitudinal studies are needed to better understand temporal changes in mobility and symptoms across the treatment trajectory to optimally time, design, and implement strategies, to preserve functioning in patients with hematologic cancer in the long term.

Patterns and predictors of functional decline after alloHCT in older adults

BACKGROUND

As allogeneic hematopoietic cell transplantation (alloHCT) is increasingly offered to older adults, geriatric assessments (GA) have 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.

OBJECTIVES

The objectives of this study are to 1) describe the longitudinal change in GA and QOL measures after alloHCT and to 2) identify predictors of greater functional decline post-transplant.

STUDY DESIGN

In this single-center prospective cohort study, patients aged 50 years or older planning to undergo 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 after transplant. Changes in GA and QOL measures at each post-transplant time point (3, 6, or 12 months) compared to baseline were analyzed using paired t-tests. Exploration of potential predictors of greater post-transplant functional decline, as measured by instrumental activities of daily living (IADL) and Medical Outcomes Study Physical Health scale (MOS-PH), were examined using linear regressions and chi-squared two-sample test of proportions.

RESULTS

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 time points post-transplant. Differences in baseline clinical characteristics were not associated with any differences in functional trajectories. Differences in baseline GA measures (patient-rated KPS, IADL, MOS-PH, Timed-Up-and-Go, Blessed Orientation-Memory-Concentration test, 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 IADL decline at 3 months still had functional decline at 6 months, though a portion did have functional recovery by 12 months. Compared to those with improved/maintained IADL at 3 months, those with declined IADL at 3 months were significantly more likely to have persistent functional decline at 6 months (p<0.0001) and 12 months (p=0.02).

CONCLUSIONS

In older alloHCT patients, mean functional status declines short-term after alloHCT with possibility of recovery by 6 to 12 months, while mean mental and emotional health improve post-alloHCT. Functional decline at 3 months post-alloHCT is associated with persistent functional decline at 12 months.

Haematopoietic stem-cell transplantation in older adults: geriatric assessment, donor considerations, and optimisation of care

Haematopoietic stem-cell transplantation (HSCT) has seen substantial growth among older adults. Chronological age is no longer viewed as an absolute barrier to HSCT, and alternative methods for assessing pre-transplantation fitness are increasingly used. In this Series paper, we summarise the metrics for pre-transplantation risk assessment in older adults, including both traditional metrics and geriatric assessment, and the ability of these metrics to predict post-transplantation outcomes. We also discuss strategies to broaden the utility of geriatric assessment, including in chronologically younger HSCT candidates and to guide individualised pre-transplantation interventions. Finally, we discuss donor considerations in older adults, including use of older sibling donors, haploidentical donors, and emerging data for donor-associated clonal haematopoiesis of indeterminate potential.