The Impact of Frailty on Traumatic Brain Injury Outcomes: An Analysis of 691 821 Nationwide Cases

Association Between Frailty and Head Impact Location After Ground-Level Fall in Older Adults

BACKGROUND

Mild traumatic brain injuries (TBIs) are highly prevalent in older adults, and ground-level falls are the most frequent mechanism of injury.

OBJECTIVE

This study aimed to assess whether frailty was associated with head impact location among older patients who sustained a ground-level fall-related, mild TBI. The secondary objective was to measure the association between frailty and intracranial hemorrhages.

METHODS

We conducted a planned sub-analysis of a prospective observational study in two urban university-affiliated emergency departments (EDs). Patients 65 years and older who sustained a ground-level fall-related, mild TBI were included if they consulted in the ED between January 2019 and June 2019. Frailty was assessed using the Clinical Frailty Scale (CFS). Patients were stratified into the following three groups: robust (CFS score 1-3), vulnerable-frail (CFS score 4-6), and severely frail (CFS score 7-9).

RESULTS

A total of 335 patients were included; mean ± SD age was 86.9 ± 8.1 years. In multivariable analysis, frontal impact was significantly increased in severely frail patients compared with robust patients (odds ratio [OR] 4.8 [95% CI 1.4-16.8]; p = 0.01). Intracranial hemorrhages were found in 6.2%, 7.5%, and 13.3% of robust, vulnerable-frail, and severely frail patients, respectively. The OR of intracranial hemorrhages was 1.24 (95% CI 0.44-3.45; p = 0.68) in vulnerable-frail patients and 2.34 (95% CI 0.41-13.6; p = 0.34) in those considered severely frail.

CONCLUSIONS

This study found an association between the level of frailty and the head impact location in older patients who sustained a ground-level fall. Our results suggest that head impact location after a fall can help physicians identify frail patients. Although not statistically significant, the prevalence of intracranial hemorrhage seems to increase with the level of frailty.

From admission to vaccination: COVID-19 vaccination patterns and their relationship with hospitalization in trauma patients

BACKGROUND

COVID-19 vaccination rates in the hospitalized trauma population are not fully characterized and may lag behind the general population. This study aimed to outline COVID-19 vaccination trends in hospitalized trauma patients and examine how hospitalization influences COVID-19 vaccination rates.

METHODS

We conducted a retrospective institutional study using our trauma registry paired with the COVID-19 vaccination ENCLAVE registry. We included patients ≥18 years admitted between April 21, 2021 and November 30, 2022. Our primary outcome was the change in vaccination posthospitalization, and secondary analyzed outcomes included temporal trends of vaccination in trauma patients and predictors of non-vaccination. We compared pre and posthospitalization weekly vaccination rates. We performed joinpoint regression to depict temporal trends and multivariate regression for predictors of nonvaccination.

RESULTS

The rate of administration of the first vaccine dose increased in the week after hospitalization (P = .018); however, this increase was not sustained in the following weeks. The percentage of unvaccinated patients declined faster in the general population in Massachusetts compared to the hospitalized trauma population. By the conclusion of the study, 27.1% of the trauma population was unvaccinated, whereas <5% of the Massachusetts population was unvaccinated. Urban residence, having multiple hospitalizations, and experiencing moderate to severe frailty were associated with vaccination. Conversely, being in the age groups 18 to 45 years and 46 to 64 years, as well as having Medicaid or self-pay insurance, were linked to being unvaccinated.

CONCLUSION

Hospitalization initially increased the rate of administration of the first vaccine dose in trauma patients, but the effect was not sustained. By the conclusion of the study period, a greater percentage of trauma patients were unvaccinated compared to the general population of Massachusetts. Strategies for sustained health care integration need to be developed to address this ongoing challenge in the high-risk trauma population.

Assessing the mFI-5 frailty score and functional status in geriatric patients undergoing inguinal hernia repairs

PURPOSE

The modified 5-factor frailty index (mFI-5) is a prognostic tool based on five comorbidities from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database-hypertension, congestive heart failure, chronic obstructive pulmonary disease (COPD), diabetes, and non-independent functional status. Our study investigates the mFI-5 index's ability to predict morbidity, length of stay (LOS), and discharge destination in geriatric patients undergoing inguinal hernia repairs, as well as assesses the interplay of baseline functional status.

METHODS

Patients aged ≥ 65 years who underwent inguinal or femoral hernia repairs from the 2018-2020 NSQIP database were studied. Separate analyses were performed for emergent and elective cohorts. Stratification was performed according to the sum of mFI-5 variables: mFI = 0, mFI = 1, mFI ≥ 2.

RESULTS

A total of 41,897 consisted of 92.9% elective and 7.1% emergent cases. The sample was 37.8% mFI = 0, 47.2% mFI = 1, and 15.0% mFI ≥ 2. Median age was 73 (IQR 68-78). Of emergent mFI ≥ 2 cases, 24.2% had non-independent functional status, versus only 4.8% in elective cases. Area under the curve was calculated for emergent and elective groups, including mortality (0.86, 0.80), pneumonia (0.82, 0.77), discharge destination not home (0.78, 0.73), prolonged LOS (0.69, 0.66), and infection (0.71, 0.62). Of index variables, dependent functional status was correlated with increased complications in elective and emergent cohorts, while COPD was significant in elective cases (OR > 2.0, p < 0.05).

CONCLUSION

The mFI-5 is predictive of complications in geriatric inguinal hernia repairs, especially in emergent cases. Frail patients with non-independent functional status are most at risk and, thus require proactive and watchful perioperative care.

Frailty Is Associated With Decreased Survival in Adult Patients With Nonoperative and Operative Traumatic Subdural Hemorrhage: A Retrospective Cohort Study of 381,754 Patients

Objective

We investigated frailty's impact on traumatic subdural hematoma (tSDH), examining its relationship with major complications, length of hospital stay (LOS), mortality, high level of care discharges, and survival probabilities following nonoperative and operative management.

Background

Despite its frequency as a neurosurgical emergency, frailty's impact on tSDH remains underexplored. Frailty characterized by multisystem impairments significantly predicts poor outcomes, necessitating further investigation.

Methods

A retrospective study examining tSDH patients ≥18 years and assigned an abbreviated injury scale score ≥3, and entered into ACS-TQIP between 2007 and 2020. We employed multivariable analyses for risk-adjusted associations of frailty and our outcomes, and Kaplan-Meier plots for survival probability.

Results

Overall, 381,754 tSDH patients were identified by mFI-5 as robust-39.8%, normal-32.5%, frail-20.5%, and very frail-7.2%. There were 340,096 nonoperative and 41,658 operative patients. The median age was 70.0 (54.0-81.0) nonoperative, and 71.0 (57.0-80.0) operative cohorts. Cohorts were predominately male and White. Multivariable analyses showed a stepwise relationship with all outcomes P < 0.001; 7.1% nonoperative and 14.9% operative patients had an 20% to 46% increased risk of mortality, that is, nonoperative: very frail (HR: 1.20 [95% CI: 1.13-1.26]), and operative: very frail (HR: 1.46 [95% CI: 1.38-1.55]). There were precipitous reductions in survival probability across mFI-5 strata.

Conclusion

Frailty was associated with major complications, LOS, mortality, and high level care discharges in a nationwide population of 381,754 patients. While timely surgery may be required for patients with tSDH, rapid deployment of point-of-care risk assessment for frailty creates an opportunity to equip physicians in allocating resources more precisely, possibly leading to better outcomes.

Neurosurgical perioperative management of frail elderly patients

With the rapid increase in global aging, the prevalence of frailty is increasing and frailty has emerged as an emerging public health burden. Frail elderly patients suffer from reduced homeostatic reserve capacity, which is associated with a disproportionate decline in physical status after exposure to stress and an increased risk of adverse events. Frailty is closely associated with changes in the volume of the white and gray matter of the brain. Sarcopenia has been suggested to be an important component of frailty, and reductions in muscle strength and muscle mass lead to reductions in physical function and independence, which are critical factors contributing to poor prognosis. Approximately 10-32% of patients undergoing neurological surgery are frail, and the risk of frailty increases with age, which is significantly associated with the occurrence of adverse postoperative events (major complications, total duration of hospitalization, and need for discharge to a nursing facility). The postoperative mortality rate in severely frail patients is 9-11 times higher than that in non-frail individuals. Therefore, due attention must be paid to neurosurgical frailty and muscle assessment in elderly patients. Specialized interventions in the perioperative period of neurosurgery in frail elderly patients may improve their postoperative prognosis.

Clinical frailty scale as a predictor of outcome in elderly patients affected by moderate or severe traumatic brain injury

Background

Older age is a well-known risk factor for unfavorable outcome in traumatic brain injury (TBI). However, many older people with TBI respond well to aggressive treatments, suggesting that chronological age and TBI severity alone may be inadequate prognostic markers. Frailty is an age-related homeostatic imbalance of loss of physiologic and cognitive reserve resulting in both limitation in autonomy of activities of daily living and vulnerability to adverse events. We hypothesized that frailty would be associated with 6-month adverse functional outcome in older people affected by moderate or severe TBI.

Methods

This was a single-center prospective observational study. We enrolled consecutive patients aged ≥65 years after TBI with Glasgow Coma Scale ≤13 and admitted to our Neurosurgical Intensive Care Unit. Frailty was evaluated by Clinical Frailty Scale (CFS). Relationships between TBI severity, frailty and extended Glasgow Outcome Scale (GOSE) at 6-month were evaluated.

Results

Sixty patients were studied, 65% were males, their age was 76 years (IQR 70-80) and their admission GCS was 8 (IQR 6-11) with a GCS motor score of 5 (IQR 4-5). Twenty eight were vulnerable-frail (defined as CFS ≥ 4). Vulnerable-frail patients showed greater 6-month mortality and unfavorable outcome compared to non-frail [87% vs. 30% OR and 95% CI: 15.7 (3.9-55.2), p < 0.0001 and 92% vs. 51% OR and 95% CI: 9.9 (2.1-46.3), p = 0.002]. In univariate analysis patients with unfavorable outcome were more frequently male and vulnerable-frail, had a higher prevalence of pre-existing neurodegenerative disease, abnormal pupil, lower GCS and had worst CT scan characteristics. At multivariate analysis, only CFS ≥ 4 and traumatic subarachnoid hemorrhage remained associated to 6-month outcome.

Conclusion

Frailty was associated with 6 month-outcome, suggesting that the pre-injury functional status could represent an additional indicator to stratify patient's severity and to predict outcome.

Impact of Frailty Risk on Adverse Outcomes after Traumatic Brain Injury: A Historical Cohort Study

We evaluated the utility of the Hospital Frailty Risk Score (HFRS) as a predictor of adverse events after hospitalization in a retrospective analysis of traumatic brain injury (TBI). This historical cohort study analyzed the data of patients hospitalized with TBI between April 2014 and August 2020 who were registered in the JMDC database. We used HFRS to classify the patients into the low- (HFRS < 5), intermediate- (HFRS5-15), and high- (HFRS > 15)-frailty risk groups. Outcomes were the length of hospital stay, the number of patients with Barthel Index score ≥ 95 on, Barthel Index gain, and in-hospital death. We used logistic and linear regression analyses to estimate the association between HFRS and outcome in TBI. We included 18,065 patients with TBI (mean age: 71.8 years). Among these patients, 10,139 (56.1%) were in the low-frailty risk group, 7388 (40.9%) were in the intermediate-frailty risk group, and 538 (3.0%) were in the high-frailty risk group. The intermediate- and high-frailty risk groups were characterized by longer hospital stays than the low-frailty risk group (intermediate-frailty risk group: coefficient 1.952, 95%; confidence interval (CI): 1.117−2.786; high-frailty risk group: coefficient 5.770; 95% CI: 3.160−8.379). The intermediate- and high-frailty risk groups were negatively associated with a Barthel Index score ≥ 95 on discharge (intermediate-frailty risk group: odds ratio 0.645; 95% CI: 0.595−0.699; high-frailty risk group: odds ratio 0.221; 95% CI: 0.157−0.311) and Barthel Index gain (intermediate-frailty risk group: coefficient −4.868, 95% CI: −5.599−−3.773; high-frailty risk group: coefficient −19.596, 95% CI: −22.242−−16.714). The intermediate- and high-frailty risk groups were not associated with in-hospital deaths (intermediate-frailty risk group: odds ratio 0.901; 95% CI: 0.766−1.061; high-frailty risk group: odds ratio 0.707; 95% CI: 0.459−1.091). We found that HFRS could predict adverse outcomes during hospitalization in TBI patients.