Impact of frailty on surgery for glioblastoma: a critical evaluation of patient outcomes and caregivers’ perceptions in a developing country

Abstract

OBJECTIVEThe authors aimed to evaluate the impact of age and frailty on the surgical outcomes of patients with glioblastoma (GBM) and to assess caregivers’ perceptions regarding postdischarge care and challenges faced in the developing country of India.METHODSThis was a retrospective study of patients with histopathologically proven GBM from 2009 to 2018. Data regarding the clinical and radiological characteristics as well as surgical outcomes were collected from the institute’s electronic database. Taking Indian demographics into account, the authors used the cutoff age of 60 years to define patients as elderly. Frailty was estimated using the 11-point modified frailty index (mFI-11). Patients were divided into three groups: robust, with an mFI score of 0; moderately frail, with an mFI score of 1 or 2; and severely frail, with an mFI score ≥ 3. A questionnaire-based survey was done to assess caregivers’ perceptions about postdischarge care.RESULTSOf the 276 patients, there were 93 (33.7%) elderly patients and 183 (66.3%) young or middle-aged patients. The proportion of severely frail patients was significantly more in the elderly group (38.7%) than in the young or middle-aged group (28.4%) (p < 0.001). The authors performed univariate and multivariate analysis of associations of different short-term outcomes with age, sex, frailty, and Charlson Comorbidity Index. On the multivariate analysis, only frailty was found to be a significant predictor for in-hospital mortality, postoperative complications, and length of hospital and ICU stay (p < 0.001). On Cox regression analysis, the severely frail group was found to have a significantly lower overall survival rate compared with the moderately frail (p = 0.001) and robust groups (p < 0.001). With the increase in frailty, there was a concomitant increase in the requirement for readmissions (p = 0.003), postdischarge specialist care (p = 0.001), and help from extrafamilial sources (p < 0.001). Greater dissatisfaction with psychosocial and financial support among the caregivers of severely frail patients was seen as they found themselves ill-equipped to provide postdischarge care at home (p < 0.001).CONCLUSIONSFrailty is a better predictor of poorer surgical outcomes than chronological age in terms of duration of hospital and ICU stay, postoperative complications, and in-hospital mortality. It also adds to the psychosocial and financial burdens of the caregivers, making postdischarge care challenging.

A matter of frailty: the modified Subdural Hematoma in the Elderly (mSHE) score

“…A systematic review of the literature on ASDH in the elderly [ 33 ] identified the presence of comorbidities to influence the outcome but also evinced the lack of literature objectively assessing comorbidities and frailty with validated instruments. While the evidence is only beginning to emerge on the importance of frailty assessment in CSDH, recent studies have illustrated how it can aid clinicians in prognostication in other neurosurgical pathologies, including glioblastoma [ 34 ], meningioma [ 35 ], and other primary central nervous system tumors [ 36 ]. Thus, the inclusion of this additional criterion into prognostication tools in CSDH appears warranted.…”

Frailty in Patients Undergoing Surgery for Brain Tumors: A Systematic Review of the Literature

“…Reported thresholds in mFI-11 scores differed by study and were similarly reported as either integers or as fractions. Cloney and Katiyar categorized patients into three integer-based categories: low frailty (0) vs. moderate frailty (1-2) vs. high frailty (≥ 3) [14,24]. Schneider used three similar categories reported as fractions based on a denominator of 11 (least-frail (0-0.08) vs. moderately-frail (0.09-0.26) vs. frailest (≥ 0.27)) [27].…”

“…Frailty status as ascertained by the mFI-5 was associated with mortality, complications, LOS, charges, discharge disposition, operation time, and readmissions [15, 17-20, 22, 26]. Frailty status using the mFI-11 was associated with in-hospital mortality, overall survival, complications, LOS, charges, discharge disposition, end of life care needs, and reoperation rates [13,14,22,24,25,27,30,31]. Frailty using the JHACG tool was associated with mortality, complications, reoperation rates, LOS, charges, costs, discharge disposition, and readmissions [11,12,28,29].…”

Frailty in Glioblastoma Is Independent From Chronological Age

“…At the time of discharge, the mean KPS was 85 (range 30-100), mean ECOG was two (range 0-4). On admission, geriatric patients with glioblastoma had a median GFI of five (range 1-11) and a median G8 score of 12 (6)(7)(8)(9)(10)(11)(12)(13)(14)(15). According to GFI, 43 (41.34%) geriatric patients with glioblastoma showed no signs of frailty, 51 (49.04%) according to the G8 Questionnaire.…”

“…A growing body of evidence suggests that frailty is a more appropriate predictor of surgical outcome, post-operative complications, and impaired overall survival than chronological age (11). Although frailty screening tests offer assessment tools to stratify geriatric patients and identify those at risk for a detrimental outcome, they are not commonly used in informing surgical decisions (12).…”