Geriatric Assessment Optimizes Older Patients for Bone Marrow Transplant

As medical advancements in conditioning regimens and supportive care continue to evolve, the age of patients eligible for hematopoietic stem cell transplantation has climbed significantly. According to Rita M. Jakubowski, NP, Clinical Program Director of Nursing at Mount Sinai, the focus has shifted toward a systematic, "age-friendly" multidisciplinary approach to ensure these older adults can withstand the rigors of treatment.

The Shift in Transplant Demographics

In a recent interview with Oncology Nursing News, Jakubowski noted that while bone marrow transplants (BMT) were historically reserved for patients in their 40s or 50s, it is now common to see patients in their 70s undergoing the procedure. However, this older population presents unique challenges for oncology nurses, as they often arrive with existing comorbidities such as cardiac issues or decreased physical strength.

"Age friendly looks at multiple domains in a ... systematic process essentially to optimize older patients prior to transplant," Jakubowski explained. She described it as a multidisciplinary effort that identifies "medical, functional, and psychosocial limitations of an older person and places him or her on a continuous spectrum of fitness, vulnerability, and frailty."

Implementing Geriatric Assessments

The core of this optimization strategy is the geriatric assessment. At Mount Sinai, Jakubowski noted that patients aged 65 and older — and in some cases, those 60 and older — receive a comprehensive evaluation before proceeding to transplant. This assessment is not a single test but a battery of evaluations including:

• Cognitive Function: Using tools like the Montreal Cognitive Assessment (MoCA) to check memory and recall.
• Frailty and Physicality: Assessing the patient's functional status and physical reserve.
• Nutritional and Pharmacological Review: Evaluating nutritional status and performing polypharmacy assessments to manage multiple medications.
• Laboratory Markers: Checking specific blood markers, such as inflammatory markers, to gauge the patient's biological status.

The CHARM Study and Predictive Tools

Jakubowski highlighted the CHARM study, an initiative by the Bone Marrow Transplant Clinical Trials Network (BMT CTN) and NMDP, which utilizes these assessment tools to identify patients at higher risk for non-relapse mortality within one year. By identifying these risks early, the clinical team can intervene to improve a patient's performance status before the transplant begins.

"The goal with any geriatric assessment is to optimize these patients prior to having a transplant because even with the reduced intensity conditioning, it's really a rough regimen to go through," Jakubowski said. "These patients need to have some reserve that they can rely on to get through it."

Improving Nursing Outcomes

For oncology nurses, these assessments provide a roadmap for care. Beyond age and cardiac status, the evaluation also considers the patient's support system, specifically whether they have a dedicated caregiver. The ultimate objective is to reduce complications during the hospital stay and ensure a smoother recovery following discharge. By utilizing these systematic processes, clinicians can better determine a patient’s "fitness" versus "frailty," leading to more informed decisions and improved survival chances for older adults battling disease.