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

Correlation of preoperative frailty with postoperative delirium and one-year mortality in Chinese geriatric patients undergoing noncardiac surgery: Study protocol for a prospective observational cohort study

BACKGROUND

To Frailty is associated with postoperative delirium (POD) but is rarely assessed in patients undergoing noncardiac surgery. In this study, the correlation between preoperative frailty and POD, one-year mortality will be investigated in noncardiac Chinese geriatric surgery patients.

METHODS

This study is a prospective, observational, cohort study conducted at a single center with Chinese geriatric patients. Patients who undergo noncardiac surgery and are older than 70 years will be included. A total of 536 noncardiac surgery patients will be recruited from the First Affiliated Hospital of Shandong First Medical University for this study. The Barthel Index (BI) rating will be used to assess the patient's ability to carry out everyday activities on the 1st preoperative day. The modified frailty index (mFI) will be used to assess frailty. Patients in the nonfrailty group will have an mFI < 0.21, and patients in the frailty group will have an mFI ≥ 0.21. The primary outcome is the incidence of POD. Three-Minute Diagnostic Interview for CAM-defined Delirium (3D-CAM) will be conducted twice daily during the 1st-7th postoperative days, or just before discharge. The secondary outcomes will include one-year mortality, in-hospital cardiopulmonary events, infections, acute renal injury, and cerebrovascular events.

DISCUSSION

This study will clarify the correlation of preoperative frailty with POD and one-year all-cause mortality in Chinese geriatric patients undergoing noncardiac surgery. Can preoperative frailty predict POD or one-year mortality? In the face of China's serious aging social problems, this result may have important clinical value for the surgical treatment of geriatric patients.

TRIAL REGISTRATION

This protocol has been registered with ClinicalTrials. Gov on 12 January 2022 (https://clinicaltrials.gov/ct2/show/NCT05189678).

The Hospital Frailty Risk Score Independently Predicts Postoperative Outcomes in Glioblastoma Patients

OBJECTIVE

The Hospital Frailty Risk Score (HFRS) is a tool for quantifying patient frailty using International Classification of Diseases, Tenth Revision codes. This study aimed to determine the utility of the HFRS in predicting surgical outcomes after resection of glioblastoma (GBM) and compare its prognostic ability with other validated indices such as American Society of Anesthesiologists score and Charlson Comorbidity Index.

METHODS

A retrospective analysis was conducted using a GBM patient database (2017-2019) at a single institution. HFRS was calculated using International Classification of Diseases, Tenth Revision codes. Bivariate logistic regression was used to model prognostic ability of each frailty index, and model discrimination was assessed using area under the receiver operating characteristic curve. Multivariate linear and logistic regression models were used to assess for significant associations between HFRS and continuous and binary postoperative outcomes, respectively.

RESULTS

The study included 263 patients with GBM. The HFRS had a significantly greater area under the receiver operating characteristic curve compared with American Society of Anesthesiologists score (P = 0.016) and Charlson Comorbidity Index (P = 0.037) for predicting 30-day readmission. On multivariate analysis, the HFRS was significantly and independently associated with hospital length of stay (P = 0.0038), nonroutine discharge (P = 0.018), and 30-day readmission (P = 0.0051).

CONCLUSIONS

The HFRS has utility in predicting postoperative outcomes for patients with GBM and more effectively predicts 30-day readmission than other frailty indices. The HFRS may be used as a tool for optimizing clinical decision making to reduce adverse postoperative outcomes in patients with GBM.

Strategies to Assess and Manage Frailty among Patients Diagnosed with Primary Malignant Brain Tumors

OPINION STATEMENT

Frailty refers to a biologic process that results in reduced physiologic and functional reserve. Patients diagnosed with primary malignant brain tumors experience high symptom burden from tumor and tumor-directed treatments that, coupled with previous comorbidities, may contribute to frailty. Within the primary malignant brain tumor population, frailty is known to associate with mortality, higher healthcare utilization, and increased risk of postoperative complications. As such, methods to assess and manage frailty are paramount. However, there is currently no clear consensus on how to best assess and manage frailty throughout the entirety of the disease trajectory. Given the association between frailty and health outcomes, more research is needed to determine best practice protocols for the assessment and management of frailty among patients diagnosed with primary malignant brain tumors.

Frailty and postoperative outcomes in brain tumor patients: a systematic review subdivided by tumor etiology

PURPOSE

Frailty has gained prominence in neurosurgical oncology, with more studies exploring its relationship to postoperative outcomes in brain tumor patients. As this body of literature continues to grow, concisely reviewing recent developments in the field is necessary. Here we provide a systematic review of frailty in brain tumor patients subdivided by tumor type, incorporating both modern frailty indices and traditional Karnofsky Performance Status (KPS) metrics.

METHODS

Systematic literature review was performed using PRISMA guidelines. PubMed and Google Scholar were queried for articles related to frailty, KPS, and brain tumor outcomes. Only articles describing novel associations between frailty or KPS and primary intracranial tumors were included.

RESULTS

After exclusion criteria, systematic review yielded 52 publications. Amongst malignant lesions, 16 studies focused on glioblastoma. Amongst benign tumors, 13 focused on meningiomas, and 6 focused on vestibular schwannomas. Seventeen studies grouped all brain tumor patients together. Seven studies incorporated both frailty indices and KPS into their analyses. Studies correlated frailty with various postoperative outcomes, including complications and mortality.

CONCLUSION

Our review identified several patterns of overall postsurgical outcomes reporting for patients with brain tumors and frailty. To date, reviews of frailty in patients with brain tumors have been largely limited to certain frailty indices, analyzing all patients together regardless of lesion etiology. Although this technique is beneficial in providing a general overview of frailty's use for brain tumor patients, given each tumor pathology has its own unique etiology, this combined approach potentially neglects key nuances governing frailty's use and prognostic value.

Assessment of the impact of frailty on adverse surgical outcomes in patients undergoing surgery for intracranial tumors using modified frailty index: A systematic review and meta-analysis

BACKGROUND

Modified frailty index (MFI) is an emerging quantitative measure of frailty; however, the quantified risk of adverse outcomes in surgeries for intracranial tumors associated with increasing MFI scores has not been thoroughly reviewed in a comprehensive manner.

METHODS

MEDLINE (PubMed), Scopus, Web of Science, and Embase were searched to identify observational studies on the association between 5 and 11 item-modified frailty index (MFI) and perioperative outcomes for neurosurgical procedures including complications, mortality, readmission, and reoperation rate. Primary analysis pooled all comparisons with MFI scores greater than or equal to 1 versus non-frail participants using mixed-effects multilevel model for each outcome.

RESULTS

In total, 24 studies were included in the review and 19 studies with 114,707 surgical operations were included in the meta-analysis. While increasing MFI scores were associated with worse prognosis for all included outcomes, reoperation rate was only significantly higher in patients with MFI ≥ 3. Among surgical pathologies, glioblastoma was influenced by a greater extent to the impact of frailty on complications and mortality that most other etiologies. In agreement with qualitative evaluation of the included studies, meta-regression did not reveal association between mean age of the comparisons and complications rate.

CONCLUSION

The results of this meta-analysis provides quantitative risk assessment of adverse outcomes in neuro-oncological surgeries with increased frailty. The majority of literature suggests that MFI is a superior and independent predictor of adverse outcomes compared to age.

The Association of Preoperative Frailty and Neighborhood-Level Disadvantage with Outcome in Patients with Newly Diagnosed High Grade Glioma

OBJECTIVE

Individual patient and socioeconomic factors are underexplored prognostic factors for glioblastoma (GBM). Frailty, a measure of physiological vulnerability, and area deprivation, a measure of socioeconomic status, are easily obtained during the preoperative evaluation. These metrics are predictors of outcome and access to treatments for other cancers. Therefore, we sought to determine the association of frailty and neighborhood disadvantage with outcomes of patients with newly diagnosed GBM.

METHODS

This was a retrospective review of newly diagnosed patients with GBM undergoing surgery from 2015 through 2020. The 5-factor modified frailty index and national area deprivation index were determined for each patient.

RESULTS

There were 244 patients. Compared with patients with "some or no" frailty, patients with "significant" frailty had a shorter median survival: 273 days (95% confidence interval [CI] 126-339) versus 393 days (95% CI 317-458), P = 0.008. The median survival for patients living in the most disadvantaged neighborhoods, 210 days (95% CI 134-334), was significantly lower than for those living in the least, 384 days (95% CI 239-484), P = 0.17. Twenty-five percent of patients living in the most disadvantaged neighborhoods did not receive postoperative chemoradiation compared with 11% of patients in the least disadvantaged neighborhoods, P = 0.046. Similarly, patients of color were less likely to receive standard of care chemoradiation than White patients.

CONCLUSIONS

Increasing frailty and neighborhood disadvantage predict worse outcomes in newly diagnosed patients with GBM undergoing surgery. Patients living in the most-deprived neighborhoods are less likely to receive postoperative chemoradiation. Identification of nontraditional predictors of treatment access and survival will inform mitigation strategies and improve outcomes.

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

BACKGROUND

Emerging literature suggests that frailty may be an important driver of postoperative outcomes in patients undergoing surgery for brain tumors. We systematically reviewed the literature on frailty in patients with brain tumor with respect to 3 questions: What methods of frailty assessment have been applied to patients with brain tumor? What thresholds have been defined to distinguish between different levels of frailty? What clinical outcomes does frailty predict in patients with brain tumor?

METHODS

A literature search was conducted using PubMed, Embase, The Cochrane Library, Web of Science, Scopus, and ClinicalTrials.gov. Included studies were specific to patients with brain tumor, used a validated instrument to assess frailty, and measured the impact of frailty on postoperative outcomes.

RESULTS

Of 753 citations, 21 studies met our inclusion criteria. Frailty instruments were studied, in order of frequency reported, including the 5-factor modified frailty index, 11-factor modified frailty index, Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator, and Hopkins Frailty Score. Multiple different conventions and thresholds were reported for distinguishing the levels of frailty. Clinical outcomes associated with frailty included mortality, survival, complications, length of stay, charges, costs, discharge disposition, readmissions, and operative time.

CONCLUSIONS

Frailty is an increasingly popular concept in patients with brain tumor that is associated with important clinical outcomes. However, the extant literature is largely comprised of retrospective studies with heterogeneous definitions of frailty, thresholds for defining levels of frailty, and patient populations. Further work is needed to understand best practices in assessing frailty in patients with brain tumor and applying these concepts to clinical practice.

Frailty and Neutrophil Lymphocyte Ratio as Predictors of Mortality in Patients with Catheter-Associated Urinary Tract Infections or Central Line-Associated Bloodstream Infections in the Neurosurgical Intensive Care Unit: Insights from a Retrospective Study in a Developing Country

OBJECTIVE

We aim to evaluate the role of frailty and inflammatory markers in predicting the short-term outcomes after catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI).

METHODS

Data regarding the patients' characteristics, isolates on CAUTI and CLABSI, antibiotic susceptibility, frailty (11-point Modified Frailty Index), and inflammatory markers were retrospectively collected. Their impact on the short-term outcomes was assessed using regression modeling response.

RESULTS

One hundred and one patients with CAUTI (n = 71) and CLABSI (n = 30) between January 2018 and December 2019 were included in this study. The pooled incidence rates for CAUTI were 5.50 and for CLABSI 3.58 episodes/1000 catheter-days. We observed 74.7% drug resistance in our CAUTI isolates and 93.3% in CLABSI. In the multivariate analysis, frailty (P = 0.006), neutrophil/lymphocyte ratio (NLR) (P = 0.007) and the presence of sepsis (P = 0.029) were found to be significant predictors of in-hospital mortality in CAUTI. In patients with CLABSI, frailty (P = 0.029) and NLR (P = 0.029) were found significant and along with sepsis (P = 0.069) resulted in a regression model with good accuracy in predicting mortality. The receiver operating characteristic curve showed that 11-point Modified Frailty Index and NLR as well as the regression model significantly predicted mortality with an area under the curve of 86.1%, 81.4%, and 95.4%, respectively, in CAUTI, and 70.9%, 77.8%, and 95.2%, respectively, in CLABSI.

Sarcopenia Diagnosed Using Masseter Muscle Diameter as a Survival Correlate in Elderly Patients with Glioblastoma

BACKGROUND

Elderly patients with glioblastoma (GBM) have a worse prognosis than do younger patients. The present study aimed to identify the patient, treatment, and imaging features, including measures of sarcopenia, associated with worse survival and 90-day postoperative mortality for elderly patients with GBM.

METHODS

A single-center retrospective study was conducted of patients aged ≥79 years at surgery who had undergone biopsy or resection of a World Health Organization grade IV GBM at the initial diagnosis. Imaging features of sarcopenia were collected, including the masseter and temporalis muscle diameters. Multivariate analyses were performed to identify factors associated with survival and 30-day complications.

RESULTS

The cohort included 110 patients with a mean age of 82.8 years at surgery and a median preoperative Karnofsky performance scale score of 80. The majority of patients underwent a surgical resection (66.4%) while a minority underwent biopsy (33.6%). Adjuvant chemo- and/or radiation therapy were used in 72.5% of the cohort. On multivariate analysis, age (hazard ratio [HR], 7.97; 95% confidence interval [CI], 1.63-36.3), adjuvant therapy (RT or TMZ vs. none: HR, 0.12; 95% CI, 0.05-0.3; RT plus TMZ vs. none: HR, 0.05; 95% CI, 0.02-0.14), surgical resection (HR, 0.46; 95% CI, 0.24-0.9), multifocality (HR, 2.7; 95% CI, 1.14-6.4), and masseter diameter (HR, 0.12; 95% CI, 0.02-0.78) were associated with survival. Masseter diameter was the only factor associated with 90-day mortality after surgical resection (P = 0.044).

CONCLUSIONS

GBM patients over the age of 79 have acceptable outcomes after resection, followed by adjuvant chemotherapy and RT. In addition to the treatment factors that predicted for survival, a decreased masseter diameter on preoperative imaging, a marker of sarcopenia, was associated with shorter overall survival and 90-day mortality after surgical resection.

Frailty in Glioblastoma Is Independent From Chronological Age

Objective: Treatment of glioblastoma in elderly patients is particularly challenging due to their general condition and comorbidities. Treatment decisions are often based on chronological age. Frailty screening tests promise an assessment tool to stratify geriatric patients and identify those at risk for an unfavorable outcome. This study aims to evaluate the impact of age and frailty on the surgical outcome and overall survival in geriatric patients with glioblastoma. Methods: Data acquisition was conducted as a single-center retrospective analysis. From January 1st 2015, and December 31st 2019, 104 glioblastoma patients over 70 years of age were included in our study. Demographic data, tumor size, Karnofsky Performance Score (KPS), and Eastern Cooperative Oncology Group Performance Status (ECOG), as well as treatment modalities, were assessed. The Geriatric 8 health status screening tool (G8) and Groningen Frailty Index (GFI) were compiled pre-and postoperatively. Results: The mean patient age was 76.86 ± 4.11 years. Forty-nine (47%) patients were female, 55 (53%) male. Sixty-seven patients underwent microsurgical tumor resection, 37 received tumor biopsy alone. Mean G8 on admission was 12.4 ± 2.0, mean GFI 5.0 ± 2.5. In our cohort, frailty was independent of patient age, tumor size, or localization. Frailty, defined by G8 and GFI, is associated with shorter overall survival (G8: p = 0.0035; GFI: p = 0.0136) and higher numbers of surgical complications (G8: p = 0.0326; GFI: p = 0.0388). Frailer patients are more likely to receive best supportive care (p = 0.004). Nevertheless, frailty did not affect adjuvant treatment decision-making toward either single-use of chemo- or radiation therapy, stratified treatment, or concomitant therapy. The surgical decision on the extent of resection was not based on pre-operative frailty. Conclusion: In our study, frailty is a predictor of poorer surgical outcomes, post-operative complications, and impaired overall survival independent of chronological age. Frailty screening tests offer an additional assessment tool to stratify geriatric patients with glioblastoma and identify those at risk for a detrimental outcome and thus should be implemented in therapeutic decision making.

Adapting the 5-factor modified frailty index for prediction of postprocedural outcome in patients with unruptured aneurysms

OBJECTIVE

The 5-factor modified frailty index (mFI-5) is a practical tool that can be used to estimate frailty by measuring five accessible factors: functional status, history of diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. The authors aimed to validate the utility of mFI-5 for predicting endovascular and microsurgical treatment outcomes in patients with unruptured aneurysms.

METHODS

A prospectively maintained database of consecutive patients with unruptured aneurysm who were treated with clip placement or endovascular therapy was used. Because patient age is an important predictor of treatment outcomes in patients with unruptured aneurysm, mFI-5 was supplemented with age to create the age-supplemented mFI-5 (AmFI-5). Associations of scores on these indices with major complications (symptomatic ischemic or hemorrhagic stroke, pulmonary embolism, pneumonia, or surgical site infection requiring reoperation) were evaluated. Validation was carried out with the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2006-2017).

RESULTS

The institutional database included 275 patients (88 underwent clip placement, and 187 underwent endovascular treatment). Multivariable analysis of the surgical cohort showed that major complication was significantly associated with mFI-5 (OR 2.0, p = 0.046) and AmFI-5 (OR 1.9, p = 0.028) scores. Significant predictive accuracy for major complications was provided by mFI-5 (c-statistic = 0.709, p = 0.011) and AmFI-5 (c-statistic = 0.720, p = 0.008). The American Society of Anesthesiologists Physical Status Classification System (ASA) provided poor discrimination (area under the curve = 0.541, p = 0.618) that was significantly less than that of mFI-5 (p = 0.023) and AmFI-5 (p = 0.014). Optimal relative fit was achieved with AmFI-5, which had the lowest Akaike information criterion value. Similar results were obtained after equivalent analysis of the endovascular cohort, with additional significant associations between index scores and length of stay (β = 0.6 and p = 0.009 for mFI-5; β = 0.5 and p = 0.003 for AmFI-5). In 1047 patients who underwent clip placement and were included in the NSQIP database, mFI-5 (p = 0.001) and AmFI-5 (p < 0.001) scores were significantly associated with severe postoperative adverse events and provided greater discrimination (c-statistic = 0.600 and p < 0.001 for mFI-5; c-statistic = 0.610 and p < 0.001 for AmFI-5) than ASA score (c-statistic = 0.580 and p = 0.003).

CONCLUSIONS

mFI-5 and AmFI-5 represent potential predictors of procedure-related complications in unruptured aneurysm patients. After further validation, integration of these tools into clinical workflows may optimize patients for intervention.

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

The Subdural Hematoma in the Elderly (SHE) score was developed as a model to predict 30-day mortality from acute, chronic, and mixed subdural hematoma in the elderly population after minor or no trauma. Emerging evidence suggests frailty to be predictive of mortality and morbidity in the elderly. In this study, we aim to externally validate the SHE for chronic subdural hematoma (CSDH) alone, and we hypothesize that the incorporation of frailty into the SHE may increase its predictive power. A retrospective cohort of elderly patients with CSDH after minor or no trauma being treated at our institution was evaluated with the SHE. Thirty-day mortality and outcome were documented. Patients were assessed with the Clinical Frailty Scale (CFS), which was incorporated into a modified SHE (mSHE). Both the SHE and the mSHE were then assessed in their predictive powers through receiver operating characteristic statistics. We included 168 patients. Most (n = 124, 74%) had a favorable outcome at 30 days. Mortality was low at n = 7, 4%. The SHE failed to predict mortality (AUC = .564, p = .565). Contrarily, the mSHE performed well in both mortality (AUC = .749, p = .026) and outcome (AUC = .862, p < .001). A threshold of mSHE = 3 is predictive of mortality with a sensitivity of 50% and a specificity of 75% and of poor outcome with a sensitivity of 88% and a specificity of 64%. Frailty should be routinely evaluated in elderly individuals, as it can predict outcome and mortality, providing the possibility for medical, surgical, nutritional, cognitive, and physical exercise interventions.