Background Hematopoietic stem cell transplant (HSCT) is a curative treatment for many hematologic diseases but requires rigorous medical optimization. Dementia is considered a relative contraindication due to concerns about adherence, complications, and follow-up. However, as the population ages, more patients with cognitive impairment are being evaluated for HSCT. Aim of this study to evaluate short-term, in-hospital outcomes among dementia patients undergoing HSCT.

Methods We conducted a retrospective cohort study using the 2021 National Readmissions Database. Adult patients (≥18 years) who underwent autologous or allogeneic HSCT were identified via International Classification of Disease, 10th Revision (ICD-10) Procedure codes. Dementia diagnoses were identified using ICD-10 codes and NRD-derived flags. We extracted demographic and hospital characteristics, payer type, HSCT type and indications, baseline comorbidities including Charlson and Elixhauser Comorbidity Index. Outcomes included in-hospital mortality, ICU admission, transfusion, sepsis, graft-versus-host disease (GVHD), discharge disposition (post-acute care facility vs home), length of stay (LOS), and total hospital charges.

Survey-weighted multivariable logistic regression models were used to evaluate the independent association between dementia and binary outcomes, adjusting for age, sex, transplant type, indication, and comorbidities. Linear regression was used for continuous outcomes.

Results Of 9,458 adult HSCT recipients in 2021, 171 (1.81%) had a concomitant diagnosis of dementia. Dementia patients were older (mean age 60.4 vs 56.4 years, p = .014) and had higher comorbidity burden (Charlson Index 3.09 vs 2.71, p = .023). There were no significant differences in sex distribution or insurance type after adjusting for age. Dementia patients had significantly higher rates of malnutrition (47.3% vs 20.7%, p < .001), congestive heart failure (11.8% vs 6.9%, p = .038), hypertension (11.6% vs 6.7%, p = .022), and coagulopathy (15.5% vs 9.7%, p = .029). No differences were seen in prevalence of coronary artery disease, stroke, chronic kidney disease, diabetes, depression, or chronic lung disease.

Allogeneic HSCT was more common in the dementia group (59.4% vs. 38.5%, p < 0.001). Indication patterns also differed: acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) accounted for 40.4% of transplants in dementia patients (vs 24.9% in non-dementia), while multiple myeloma was less common (24.3% vs 40.0%).

After accounting for baseline characteristics, dementia was found to be independently associated with several adverse in-hospital outcomes. Dementia was associated with a higher odds of in-hospital mortality (adjusted odds ratio [aOR] 3.19, p < .001), ICU admission (aOR 5.41, p < .001), GVHD (aOR 2.03, p = .012), and being discharged to a post-acute care facility (aOR 10.06, p < .001). Notably, no patients in either group were discharged to hospice. Patients with dementia had significantly longer hospital stays (+13.7 days, p < .001) and higher total charges (+$344,125, p < .001). Transfusion and sepsis did not show any statistically significant difference.

Discussion This nationally representative study demonstrates that patients with dementia undergoing HSCT experience significantly higher in-hospital morbidity and mortality, even after adjusting for age, comorbidities, transplant type, and indication, establishing dementia as an independent predictor of poor peri-transplant outcomes. The elevated ICU use and GVHD rates may reflect challenges in symptom recognition and complication management in cognitively impaired patients. Additionally, the high rate of discharge to post-acute facilities underscores the reduced functional reserve and ongoing care needs of this population. The observed differences in transplant type and indication distribution may be partially explained by selection bias, as patients with more aggressive diseases (e.g., AML) may be more likely to undergo HSCT despite dementia if no alternatives exist.

Conclusion Dementia is independently associated with significantly worse in-hospital outcomes among HSCT recipients, including higher mortality, ICU use, GVHD, post-acute discharge, longer hospital stays, and greater cost. These findings highlight the urgent need for incorporating cognitive status into pre-transplant evaluation and developing supportive strategies to mitigate risks in this high-need population.

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2025
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