Exploring Cognitive Impairment in Hematologic Cancer Patients

Many older patients with hematologic cancers have another condition to worry about—one they don’t always feel comfortable discussing with their health care team. As people are living longer, memory problems have become increasingly prevalent. However, little is known about the impact of cognitive impairment, and specific domains of cognitive impairment, on older cancer patients and their survival.

A recent study led by Tammy T. Hshieh, MD, MPH, an associate physician with the Brigham and Women’s Hospital Division of Aging, sheds some light on the subject. The study of 360 patients with blood cancer, age 75 or older, found that 35.3 percent of patients screened positive for executive dysfunction and 17.2 percent screened positive for impairment in working memory. While executive function impairment was not associated with increased overall mortality, working memory impairment was, with a reduction of just over a month in median survival.

“We’re seeing more and more older patients being treated for hematologic cancers, thanks to advances in oral chemotherapy,” Dr. Hshieh said. “However, these treatments, which are often done at home, can be quite complicated in terms of scheduling and other care instructions. This makes it hard for patients with cognitive impairment to comply with treatment protocols. The cognition-impairing effect of certain chemotherapy drugs exacerbates the situation.”

According to Dr. Hshieh, the problem is especially troubling because many older patients and their families do not feel comfortable raising the issue of cognitive impairment with their oncology team.

“Patients come to the Brigham for our pioneering treatments and leadership in cutting-edge clinical trials,” she explained. “They feel that by ‘admitting’ to cognitive impairment, they aren’t putting their best foot forward and may not be offered those treatment opportunities.”

The Value of Open Communication with Providers

Dr. Hshieh stressed it is important for these patients and their families to understand that cognitive impairment is not a barrier to care and that open communication is crucial.

“We would never refuse to offer treatment options available to other patients,” she said. “Our goal is to set up all our patients for success with the treatments indicated by their oncologists.”

Setting patients up for success starts with communicating the issue to oncologists so they know to refer older patients to geriatricians for screening. Once a patient’s levels of cognitive function are assessed, the geriatrics team at the Brigham tailors an intervention plan specific to their needs.

“Patients with executive dysfunction may have underlying neurodegenerative problems that would benefit from cognitive rehabilitation,” Dr. Hshieh said. “Patients who have problems following multi-step instructions benefit from having instructions written out in clear, step-by-step language.”

In addition to working closely with the patient’s oncology team, Brigham geriatricians coordinate with patients’ primary care providers to help advocate for proper management of common co-morbidities such as diabetes and hypertension.

Towards Integrated Geriatrics Care

Dr. Hshieh noted that patients with cognitive impairment often don’t understand the urgency of their situation—for example, when an elevated temperature indicates a fever that should be reported to their physician because they are immunocompromised/neutropenic. She said problems also can be compounded when the patient’s primary caregiver also has cognitive impairment. In these cases, Brigham geriatricians will arrange for nurses to visit patients in the home to address any problems during treatment.

“We are starting to see the tide turn in terms of recognizing the importance of cognitive function in treating hematologic cancers among older patients,” Dr. Hshieh said. “Geriatrics has become more integrated with oncology. Open conversations are becoming more common. Plus, the patient population is changing and is now baby boomers, who are more proactive in maintaining their overall health and advocating for themselves compared with prior generations.”