Table 1.
Standard pretransplant optimization of older patients according to vulnerability
| Domain impaired | Intervention |
|---|---|
| Significant comorbid conditions | Use preferred subspecialty consultants |
| Optimization and stratification related to anticipated toxicities (rather than “clearance”) | |
| Ensure follow-up of comorbidity after HCT | |
| Impaired function | Determine achievable functional gains |
| Structured prehabilitation: exercises and physical therapy consultation | |
| Home safety assessment | |
| Falls | Assist devices |
| Educate on fall risks | |
| Define high-risk periods and precipitants (eg, hospitalization, IV fluids at night, sedative medications) | |
| Limited social support | Pretransplant family meeting to widen support |
| Assign “Team Captain” to coordinate caregivers | |
| Review short- and long-term patient needs to avoid nursing home or rehabilitation care | |
| Cognitive impairment | More detailed cognitive testing and/or medical evaluation |
| Delirium precautions (eg, avoid high-risk medications, educate patient and family) | |
| Education in writing and/or by recording | |
| Maximize caregivers availability, including 24/7 in hospital | |
| Depression or anxiety | Consult for cognitive behavioral therapy ± pharmacotherapy |
| Assess expected adherence post-HCT | |
| Weight loss | Exclude concurrent medical and dental problems |
| Avoid unnecessary dietary restrictions | |
| Bring preferred foods to hospital | |
| Nutritional supplements if needed | |
| Polypharmacy | Stop unnecessary medications |
| Evaluate interactions | |
| Pharmacist review of medication and use pill box | |
| Any impairment | Evaluate underlying medical problems |
| Elaborate on impairment in medical record | |
| Adjust preparative regimen | |
| Increase posttransplant follow-up frequency (visits/calls) | |
| Booster posttransplant day 30 MDC visit | |
| Harmonize patient and family needs and goals |