Is Your Patient With GVHD Frail?

By Elaine S. DeMeyer, RN, MSN, AOCN®, BMTCN® - September 7, 2023

Oncology nurses can often spot frailty immediately in patients with graft-versus-host disease (GVHD). They notice patients’ walking and posture, diminished strength, and struggles with daily living activities. However, “frailty” is a rather vague term. In a recent Transplant and Cellular Therapy article, stem cell transplant (SCT) researchers use 5 characteristics to define frailty. They conclude that “earlier clinical recognition of frailty in patients with chronic GVHD (cGVHD) may prompt interventions to counteract frailty.” Oncology nurses caring for patients with GVHD can provide an earlier frailty assessment to alert the SCT team.

Defining “Frailty”

Frailty is often associated with older age (>65 years), age-related conditions causing a high risk of disability and death, and low-performance status. The term “frailty syndrome” has emerged in the geriatric community to identify patients at risk for disease and poorer outcomes. For example, older, frail patients have a higher risk for falls with increased morbidity and mortality.

However, people living with GVHD—young and old—can develop frailty. Some studies suggest that inflammation contributes to frailty. As inflammatory markers rise, frailty is more likely to become a problem. By its physiologic nature, GVHD causes massive cytokine release, triggering inflammation. As a result, GVHD can cause physiologic frailty in younger allogeneic SCT survivors.

Using Frailty Criteria

In the article “Frailty in Patients With Chronic Graft-Versus-Host Disease,” Rashid and colleagues sought to explore the prevalence of frailty and the associated patient outcomes. The study included 399 patients in the multicenter Chronic GVHD Consortium data set. Enrolled between 2007 and 2012, patients were only long-term survivors.

The researchers defined “frailty” according to the Fried criteria, using the Lee Symptom Scale (LSS), Human Activity Profile, and specific measurements such as a walking test or grip strength. Patients qualified as “frail” if they met 3 or more of the following 5 criteria:

  1. Unintentional weight loss (LSS 2 or 3)
  2. Exhaustion (≥2 on “loss of energy” LSS question)
  3. Slow walking speed (walk test of meters in 2 minutes)
  4. Low physical activity (≤53 on Human Activity Profile)
  5. Weakness (grip strength)

Researchers compared outcomes between 129 (32%) frail patients and 270 (68%) non-frail patients. The most common frailty characteristics were exhaustion, slow walking speed, and weakness. Frail patients had higher non-relapse mortality and decreased overall survival.

Identifying Frailty With Simple Questions

From a practical, everyday standpoint, oncology nurses caring for patients with GVHD can consider asking patients:

  • Do you feel like you’re shrinking?
  • Do you feel tired or exhausted?
  • Do you walk slowly?
  • Do you have a low activity level?
  • Do you feel weak?

Patients who answer “yes” to 3 or more questions are considered frail.

Oncology nurses are vital in assessing and diagnosing frailty in patients with GVHD. Ongoing assessment for early identification or worsening of frailty with prompt communication may improve an interdisciplinary team’s approach to specific care needs and individualized interventions. Frailty can be a fluctuating syndrome that requires open communication and empowering patients with resources and services.


Frailty in Patients With Chronic Graft-Versus-Host Disease

Back to the Basics: Pathophysiology of Acute GVHD

Physiologic Frailty in Nonelderly Hematopoietic Cell Transplantation Patients

Frailty in Older Adults: Evidence for a Phenotype