The role of frailty in geriatric cranial neurosurgery for primary central nervous system neoplasms

Abstract

OBJECTIVEFrailty is a clinical state of increased vulnerability due to age-associated decline and has been well established as a perioperative risk factor. Geriatric patients have a higher risk of frailty, higher incidence of brain cancer, and increased postoperative complication rates compared to nongeriatric patients. Yet, literature describing the effects of frailty on short- and long-term complications in geriatric patients is limited. In this study, the authors evaluate the effects of frailty in geriatric patients receiving cranial neurosurgery for a primary CNS neoplasm.METHODSThe authors conducted a retrospective cohort study of geriatric patients receiving cranial neurosurgery for a primary CNS neoplasm between 2010 and 2017 by using the Nationwide Readmission Database. Demographics and frailty were queried at primary admission, and readmissions were analyzed at 30-, 90-, and 180-day intervals. Complications of interest included infection, anemia, infarction, kidney injury, CSF leak, urinary tract infection, and mortality. Nearest-neighbor propensity score matching for demographics was implemented to identify nonfrail control patients with similar diagnoses and procedures. The analysis used Welch two-sample t-tests for continuous variables and chi-square test with odds ratios.RESULTSA total of 6713 frail patients and 6629 nonfrail patients were identified at primary admission. At primary admission, frail geriatric patients undergoing cranial neurosurgery had increased odds of developing acute posthemorrhagic anemia (OR 1.56, 95% CI 1.23–1.98; p = 0.00020); acute infection (OR 3.16, 95% CI 1.70–6.36; p = 0.00022); acute kidney injury (OR 1.32, 95% CI 1.07–1.62; p = 0.0088); urinary tract infection prior to discharge (OR 1.97, 95% CI 1.71–2.29; p < 0.0001); acute postoperative cerebral infarction (OR 1.57, 95% CI 1.17–2.11; p = 0.0026); and mortality (OR 1.64, 95% CI 1.22–2.24; p = 0.0012) compared to nonfrail geriatric patients receiving the same procedure. In addition, frail patients had a significantly increased inpatient length of stay (p < 0.0001) and all-payer hospital cost (p < 0.0001) compared to nonfrail patients at the time of primary admission. However, no significant difference was found between frail and nonfrail patients with regard to rates of infection, thromboembolism, CSF leak, dural tear, cerebral infarction, acute kidney injury, and mortality at all readmission time points.CONCLUSIONSFrailty may significantly increase the risks of short-term acute complications in geriatric patients receiving cranial neurosurgery for a primary CNS neoplasm. Long-term analysis revealed no significant difference in complications between frail and nonfrail patients. Further research is warranted to understand the effects and timeline of frailty in geriatric patients.

Brain Tumor Resection in Elderly Patients: Potential Factors of Postoperative Worsening in a Predictive Outcome Model

“…The present study confirms that surgical resection of BT in patients older than 65 is feasible and rather safe [ 5 , 7 , 26 ]. The recently growing interest in elderly neuro-oncological patients has generated a series of studies that highlight how increased age (≥65 years), alone does not represent an independent risk factor associated with worse outcomes [ 27 ]. It has been demonstrated that frailty, described as the “clinically recognizable state of increased vulnerability resulting from age-associated physiological decline” [ 27 ], is per se an outcome predictor, but not the only one.…”

“…These data confirm those of Maldaner et al [ 7 ], in particular, a higher rate of perioperative complications in elderly patients. Shahrestani et al recently highlighted that the complication rate significantly differs between frail and non-frail elderly patients immediately following cranial surgery [ 27 ]. In contrast, they also suggest that there may be no significant difference in long-term follow-up.…”

“…Moreover, it seems that the role of tumor type is not a major determinant in predicting outcome: frailty in geriatric neurosurgical patients has an impact on outcome regardless of histology, also in large patients’ cohorts [ 27 ]. The abovementioned considerations are not new to recent literature: Ius et al, in a multicentric series of elderly GMB patients, excluded any correlation between the presence of comorbidities (evaluated via the CCI) and outcome or overall survival [ 9 ].…”

“…Applying such models to specific subgroups of patients that are intrinsically vulnerable to surgery (e.g., over 65 y.o.) [ 1 , 5 , 27 ] may be helpful not only to predict the postoperative course but also to make the safest decision in terms of who receives indication for BT surgery. In our study, the MCS score was associated with an increased odd of neurological worsening at discharge.…”

“…The percentage of worsened patients is similar to that found in a previous series of 746 operated BT in patients of any age [ 10 ]. The fact that older age does not appear a determining factor in shaping the postoperative outcome is recently emerging as a common finding among different centers, as Schwartz, Schar, and others pointed out [ 9 , 11 , 26 , 27 , 31 , 32 , 33 , 34 ]. On the other hand, the occurrence of complications of any grade and type (surgical and non-surgical) in the present elderly population seems to be slightly higher (46 vs. 41%) when compared to other series more heterogeneous in terms of age [ 10 ], and this has a significant impact on outcome both at discharge and at the three-month FU, regardless of the complication grade [ 17 , 25 ].…”