Dementia Frequent Among Older Patients in Line for Stem Cell Transplantation

FigureSAN FRANCISCO—Moderate and severe dementia appears to occur often among patients with hematological malignancies who are candidates for stem cell transplantation, researchers reported at the inaugural Cancer Survivorship Symposium (Abstract 32). “We found that 40 of 62 patients we evaluated had signs of mild cognitive dysfunction or full-blown dementia,” said Beatrice Edwards, MD, Associate Professor of Geriatric Medicine at the University of Texas MD Anderson Cancer Center, at her poster presentation. She said that, when given a battery of tests, 23 of the patients were diagnosed with mild cognitive impairment and 17 had dementia—12 of these people had early signs of dementia, 3 had moderate dementia, and 2 had severe dementia.Figure“People with moderate dementia means these people can no longer make decisions on their own,” she told OT. “I don't think people with moderate or severe dementia are good choices for stem cell transplant.” Edwards noted the stem cell transplantation procedure itself can be problematic. “In the procedure, the patients are going to lose function; they are going to lose cognition—do you want them coming out of stem cell transplantation and not recognizing you and going to a nursing home? That's a failure. “In older patients with hematologic malignancies, cognitive impairment is common and higher than in the cancer-free population. Cancer therapy-induced neurologic changes are superimposed on age-related changes,” she added. Beyond Hematological Malignancies While the study Edwards presented at the meeting involved patients with hematological malignancies, she also said she has a group of patients with solid tumors and found similar results. The 200 patients in both groups went through a geriatric assessment—a functional assessment, depression screen, and social support. “We did cognitive assessment and 12 percent got neuropsychological testing. This was all done before stem cell transplantation,” she said. “The patients had all been treated previously, but those treatments had failed to control the disease and now they were being evaluated prior to stem cell transplantation. Edwards said that, when she discusses the neurological testing with the patients' families, the first reaction is denial. “The families are often like ‘No, they don't have memory loss.’ and then when I start testing the patients, the family members would say ‘Well, now that you mention it, for the last year...’ The memory loss had been there for some time. This was not recent.” She said the fact that the patients had all been treated previously with chemotherapy meant the chemobrain phenomenon limited how precise the researchers could be about the type of dementia being observed. “We found a lot of ischemic changes that suggested vascular dementia and a lot of cortical atrophy that suggests Alzheimer's; but because it is also chemobrain, we just left it as dementia,” Edwards said. “It is probably a mix of dementia.” The majority of the patients in the study had received chemotherapy for more than 2 years. Edwards and her colleagues just evaluated patients referred from other institutions and clinicians. “We let the stem cell group know about our findings. We educate the family about delirium. I think the early stage is probably okay for stem cell transplantation. We do give them cognitive enhancers.” She said that, because the patients are referred from other institutions for psychiatric evaluations, the researchers did not have follow-up studies to determine outcomes—whether they underwent the stem cell procedures and how well they fared after the treatment. In commenting on the study, Gayatri Devi, MD, a Neurologist and Memory Loss Specialist at Lenox Hill Hospital, New York, told OT, “This is a relatively small study of patients over the age of 65 with hematologic cancer where a significant percentage had some level of cognitive impairment from varying causes. “Cognitive impairment does not preclude such patients from treatment,” Devi said. “However, there may be a role for routine cognitive screening in older adults with such conditions, once these results are replicated in a larger sample.” Cognitive Assessment For her study, Edwards performed a retrospective cohort analysis of older adult patients who were evaluated at the Program for Healthy Aging at MD Anderson from January 2013 through June 2014. Cognitive assessment was evaluated through personal interview, the Montreal cognitive assessment (MOCA), and a functional assessment utilizing activities of daily living. Screening for depression was conducted with the Patient Health Questionnaire (PHQ-90). Patients were interviewed regarding risk factors for dementia including depression, concussions, alcohol abuse, and family history of dementia. Level of education was assessed. Cognitive impairment was defined as an abnormal MOCA without functional impairment, and dementia was defined as an abnormal MOCA with functional impairment. Imaging and assessment for reversible factors of memory loss was conducted. Brain imaging was performed identifying white matter micro-ischemic changes, cerebrovascular accidents, and brain atrophy in some cases. No significant thyroid abnormalities, B12 deficiency, or other reversible causes were identified. Before going ahead with stem cell transplantation, Edwards said awareness of cognitive status is important. “People with cognitive impairment are at high risk of delirium,” she said. She also noted clinicians have to discuss with patients and families of the patients the treatment pros and cons. “Discussion of treatment options may be challenging,” she said, “and a supportive environment is needed for successful clinical outcomes.”

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