JAMA:关注老年血液肿瘤患者的认知障碍问题
在老年人群中,发生认知功能下降是相当常见的问题。然而,很少有研究探究这种认知下降对肿瘤患者生活和预后的影响。今年3月初,一篇发表在《JAMA oncology》上的文章探究了老年血液肿瘤患者认知障碍的流行病学及对预后影响的研究。
研究目的

确定老年血液肿瘤患者特定领域认知功能损伤的发生率,以及与总体生存期的关系。


研究设计、环境和受试者:这项前瞻性、观察性的队列研究在2015.2.1-2017.3.1期间在波士顿三级医院共纳入75岁以上初诊为白血病、骨髓瘤或淋巴瘤的老年患者。受试者接受了意志和认知障碍的筛查,并进行生存期的随访。


暴露因素:用Clock-in-the-Box (CIB)试验筛查执行功能障碍,用5个单词的延迟回忆试验来筛查记忆力下降。用Fried虚弱表型和Rockwood累积缺陷虚弱模型来评价受试者健康、潜在虚弱或虚弱的精神状态。

研究结果

在420名接触的患者中,360 (85.7%)名同意进行虚弱状态的评估(包括232名男性 [64.4%] 和128名女性 [35.6%]; 平均 [标准差] 年龄, 79.8 [3.9] 岁)。其中,341 (94.7%)名患者也完成了认知筛查检测。127 (35.3%)名患者根据CIB结果可能有执行功能障碍,62 (17.2%)人可能存在记忆力下降。这2中损害都与Fried虚弱表型存在一定相关性(CIB, ρ = 0.177; 延迟回忆, ρ = 0.170; P =0.01)。


许多表型是健康的患者也可能存在认知损害(CIB实验104人中的24 人[23.1%] 和延迟回忆试验104 人中的9人[8.7%])。按无进展肿瘤(log-rank P = .01)和进展期肿瘤(P < .001)进行分层,以及多因素分析校正了年龄、并发症和疾病进展程度后(比值比, 0.26; 95% CI, 0.13-0.50),患有记忆力损害的患者中位生存时间依然更短(10.9 [标准差, 12.9] vs 12.2 [标准差, 14.7] 月; log-rank P < .001)。在那些接受强化治疗的患者中,记忆力下降也与较差的生存期具有相关性(log-rank P < .001)。执行功能障碍只在接受强化治疗患者中提示较差的生存期(log-rank P = .03)

研究结论

这些数据说明了老年血液肿瘤患者中普遍有认知障碍,而且可能对预后有不同的预测价值。我们需要为这些弱势的患者群体提供针对性的干预措施。

原文


Objective

To determine the prevalence of domain-specific cognitive impairment and its association with overall survival among older patients with blood cancer.


Design, Setting, and Participants  

This prospective observational cohort study included all patients 75 years and older who presented for initial consultation in the leukemia, myeloma, or lymphoma clinics of a large tertiary hospital in Boston, Massachusetts, from February 1, 2015, to March 31, 2017. Patients underwent screening for frailty and cognitive dysfunction and were followed up for survival.


Exposures

The Clock-in-the-Box (CIB) test was used to screen for executive dysfunction. A 5-word delayed recall test was used to screen for impairment in working memory. The Fried frailty phenotype and Rockwood cumulative deficit model of frailty were also assessed to characterize participants as robust, prefrail, or frail.


Results 

Among 420 consecutive patients approached, 360 (85.7%) agreed to undergo frailty assessment (232 men [64.4%] and 128 women [35.6%]; mean [SD] age, 79.8 [3.9] years), and 341 of those (94.7%) completed both cognitive screening tests. One hundred twenty-seven patients (35.3%) had probable executive dysfunction on the CIB, and 62 (17.2%) had probable impairment in working memory on the 5-word delayed recall. Impairment in either domain was modestly correlated with the Fried frailty phenotype (CIB, ρ = 0.177; delayed recall, ρ = 0.170; P = .01 for both), and many phenotypically robust patients also had probable cognitive impairment (24 of 104 [23.1%] on CIB and 9 of 104 [8.7%] on delayed recall). Patients with impaired working memory had worse median survival (10.9 [SD, 12.9] vs 12.2 [SD, 14.7] months; log-rank P < .001), including when stratified by indolent cancer (log-rank P = .01) and aggressive cancer (P < .001) and in multivariate analysis when adjusting for age, comorbidities, and disease aggressiveness (odds ratio, 0.26; 95% CI, 0.13-0.50). Impaired working memory was also associated with worse survival for those undergoing intensive treatment (log-rank P < .001). Executive dysfunction was associated with worse survival only among patients who underwent intensive treatment (log-rank P = .03).、


Conclusions and Relevance  

These data suggest that domains of cognitive dysfunction may be prevalent in older patients with blood cancer and may have differential predictive value for survival. Targeted interventions are needed for this vulnerable patient population.



Reference: Prevalence of Cognitive Impairment and Association With Survival Among Older Patients With Hematologic Cancers


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