In Reply to the Letter to the Editor Regarding “Increasing Frailty Predicts Worse Outcomes and Increased Complications After Angiogram-Negative Subarachnoid Hemorrhages”

Does Frailty or Age Increase the Risk of Postoperative Complications Following Cochlear Implantation?

Objective

To evaluate whether frailty or age increases the risk of postoperative complications following cochlear implant (CI) surgery.

Study Design

Retrospective cohort study.

Setting

Tertiary academic center.

Methods

An evaluation of all adult patients undergoing cochlear implantation between 2006 and 2020 was performed. The 5-item Modified Frailty Index (mFI-5, comprising preoperative history of pulmonary disease, heart failure, hypertension, diabetes, and partially/totally dependent functional status) was calculated for all patients included in analysis in addition to demographic characteristics. The primary outcome was postoperative complications following CI within a 3-month period. Major complications included myocardial infarction, bleeding, and cerebrospinal fluid leak, among others. Predictors of postoperative complications were examined using multivariable logistic regression reporting odds ratios (ORs) and 95% CIs.

Results

There were 520 patients included for review with a median age of 68 (range, 18-94) years and a slight male predominance (n = 283, 54.4%). There were 340 patients (65.4%) who were robust (nonfrail) with an mFI of 0, while 180 (34.6%) had an mFI of ≥1. There were 20 patients who experienced a postoperative complication (3.85%). There was no statistically significant association between postoperative complications as a result of preoperative frailty (OR, 1.56; 95% CI, 0.98-2.48, P = .06) or age as a continuous variable (OR, 0.99; 95% CI, 0.97-1.02, P = .51).

Conclusions

CI is safe for elderly and frail patients and carries no additional risk of complications when compared to younger, healthier patients. While medical comorbidities should always be considered perioperatively, this study supports the notion that implantation is low risk in older, frail patients.

The Effect of Frailty versus Initial Glasgow Coma Score in Predicting Outcomes Following Chronic Subdural Hemorrhage: A Preliminary Analysis

Background Initial Glasgow Coma Score (iGCS) is a well-known predictor of adverse outcomes following chronic subdural hemorrhage (cSDH). Frailty, i.e. a reduced physiologic reserve, is associated with poorer outcomes across the surgical literature, however, there is no consensus on the best measure of frailty. To date, no study has compared frailty's ability to predict cSDH outcomes versus iGCS. The goal of this study was to, therefore, examine the prognostic value of the 5- (mFI-5) and 11-factor (mFI-11) modified frailty index, and Charlson Comorbidity Index (CCI) versus iGCS following cSDH. Methods Between January, 2016 and June, 2018, patients who presented to the emergency department with cSDH were retrospectively identified using the International Classification of Diseases (ICD) codes. mFI-5, mFI-11, and CCI scores were calculated using patient baseline characteristics. Primary endpoints were death and discharge home and subgroup analyses were performed among operative cSDH. Univariate and multivariate logistic regressions were used to determine predictors of primary endpoints. Results Of the 109 patients identified, the average age was 72.6±1.6 years and the majority (69/109, 63.3%) were male. The average CCI, mFI-5, and mFI-11 were 4.5 ±0.2, 1.5 ±0.1, and 2.2 ±0.1, respectively. Fifty (45.9%) patients required surgical intervention, 11 (10.1%) died, and 48 (43.4%) were discharged home. In the overall cohort, while the only multivariate predictor of mortality was iGCS (OR=0.58; 95%CI:0.44-0.77; p=0.0001), the CCI (OR=0.73; 95%CI:0.58-0.92; p=0.0082) was a superior predictor of discharge home compared to iGCS (OR=1.46; 95%CI:1.13-1.90; p=0.0041). Conversely, among those who received an operative intervention, the CCI, but not iGCS, independently predicted both mortality (OR=4.24; 95%CI:1.01-17.86; p=0.0491) and discharge home (OR=0.55; 95%CI:0.33-0.90; p=0.0170). Neither mFI nor age predicted primary outcomes in multivariate analysis. Conclusion While frailty is associated with worse surgical outcomes, the clinical utility of the mFI-5, mFI-11, and CCI in cSDH is unclear. We show that the iGCS is an overall superior predictor of mortality following cSDH but is outperformed by the CCI after operative intervention. Similarly, the CCI is the superior predictor of discharge home in cSDH patients overall and following an operative intervention. These results indicate that while the iGCS best predicts mortality overall, the CCI may be considered when prognosticating post-operative course and hospital disposition.

The Effect of Frailty and Patient Comorbidities on Outcomes After Acute Subdural Hemorrhage: A Preliminary Analysis

BACKGROUND

Frailty is associated with worse outcomes across a variety of neurosurgical diseases. However, its effect on acute subdural hemorrhage (aSDH) outcomes is unclear. The goal of this study is to compare 3 measures of frailty with the gold standard (i.e., initial Glasgow Coma Scale [iGCS] score) for predicting outcomes after aSDH.

METHODS

Patients who presented between January 2016 and June 2018 were retrospectively identified based on International Classification of Diseases codes for aSDH. Patients' modified Frailty Index (mFI), temporalis muscle thickness (TMT), and age-adjusted Charlson Comorbidity Index (CCI) were calculated. Primary end points were death and discharge home.

RESULTS

Of 167 patients included, the mean age was 63.4 ± 1.9 years, the average CCI was 3.4 ± 0.2, mFI was 1.4 ± 0.1, TMT was 7.1 ± 0.2 mm, and iGCS score was 11.9 ± 0.3. Sixty-nine patients (41.3%) were discharged home and 32 (19.2%) died during hospitalization. In multivariate analysis, decreasing iGCS score (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.74-0.96; P = 0.0112) and midline shift (OR, 1.27; 95% CI, 1.08-1.50; P = 0.0048), but not age or frailty, predicted mortality. In addition to iGCS score (OR, 1.26; 95% CI, 1.10-1.44; P = 0.0011), lower CCI (OR, 0.32; 95% CI, 0.14-0.74; P = 0.0071) and larger TMT (OR, 2.63; 95% CI, 1.16-5.99; P = 0.0210) independently predicted increased rates of discharge home. mFI was not independently associated with either primary end point in multivariate analysis.

CONCLUSIONS

iGCS score predicts both mortality and discharge location after aSDH better than do age or frailty. However, CCI and TMT, but not mFI, are useful prognostic indicators of discharge to home after aSDH. The iGCS score should continue to be the primary prediction tool for patients with aSDH; however, frailty may be useful for resource allocation, especially when nearing discharge.