The incidence rate of brain tumor between 2014 and 2018 was 17.18 for nonmalignant and 7.06 for malignant per 100 000 population.1 Brain tumors are a major cause of abnormal brain function,2 leading to health problems or disabilities due to different pathologies dependent on the position, size, and treatment of brain tumors.3,4 Brain tumors cause health problems because of pathology of the disease and factors related to treatment such as surgery, radiotherapy, and chemotherapy. Currently, the method most frequently selected to treat brain tumors is surgery with the goal of improving quality of life. Nevertheless, patients may have unpleasant symptoms, causing postoperative complications and disruptive effects on patients' physical, psychological, and social functioning after surgery.
Surgical frailty means a condition in which patients are weak with varied recovery of various organ functions and reduced physical, psychological, and social functions after surgery, leading to unpleasant outcomes.5,6 For instance, frailty could develop unpleasant outcomes such as decreased physical functioning, increased postoperative complications and length of stay, and neurological deficits as well as mortality. Postoperative symptoms are problems found among brain tumor patients after craniotomy during recovery that cause reduced physical function as a transition to physical dysfunction in multiple systems. Thus, postoperative symptoms were found to be correlated with frailty.7 The alteration of psychological function (ie, mood state, negative experienced discrimination) was a frequently encountered problem in brain tumor patients.8 Moreover, depression and anxiety were correlated with frailty in patients with heart failure.9 Then, brain tumor patients also had a problem with social function because they had cognitive impairment causing dependence and reduced social participation.10 Previous study on the older population also confirmed that social factors were found to be correlated with frailty.11
Researchers found that studies on neurological frailty were conducted in the Western hemisphere, which had different cultures, ethnicities, and citizenships.12 Only 2 studies examined frailty as an unpleasant outcome among postoperative brain tumor patients.13,14 Furthermore, frailty studies have been frequently conducted on other populations (ie, stroke patients, patients with heart failure, older adults) with limited knowledge of postoperative brain tumor patients. This study examines relationships between postoperative symptoms, mood states, social support, and frailty in brain tumor patients after craniotomy.
This study was a cross-sectional predictive study. The study participants were male or female patients 18 years and older who had a craniotomy to remove brain tumors at the postoperative patient ward of a university hospital in Bangkok between February and October 2021. Inclusion criteria were patients who had full consciousness with a Glasgow Coma Scale score of 15, were able to communicate in Thai, had stable vital signs in the past 24 hours, and had a postoperative duration of not more than 1 week. Researchers excluded participants who had been given a diagnosis of psychiatric problems or used a mechanical ventilator. Power analysis was used with an α of .05, a power of test at 0.80, and a medium effect size of 0.15. After calculation with the G*Power program, a sample size of 85 subjects was obtained.15
Researchers collected demographics such as age, sex, educational attainment, marital status, religion, occupation, comorbidity, income, and primary caregiver and clinical characteristic data such as brain tumor type, type of surgery, number of brain tumor surgery, and duration after the surgery to the data collection date. Frailty was used to measure the alteration of body function resulting in the compromising of individual after surgery. Frailty was assessed with the Frailty Instrument of the Survey of Health, Aging and Retirement in Europe, which examines exhaustion, weight loss, slowness, low physical activity, and weakness.16 The summation of frailty score was calculated by an online program known as the DFactor score. A higher score indicated being more frail. In this study, the internal consistency using Cronbach α was .74.
Postoperative symptoms were assessed within 24 hours using the M.D. Anderson Symptom Inventory Brain Tumor, which has high internal consistency (α = .88). The M.D. Anderson Symptom Inventory Brain Tumor uses a 0-to-10 scale (higher scores indicate more severity) to examine recovery symptoms (22 items) and symptom interference (6 items).17
Mood state was a state of feeling related to the postoperative brain tumor period measured by the Profile of Mood States 2nd Edition (Adult Short Form), which has high internal consistency (α = .90).18 The Profile of Mood States 2nd Edition consists of 35 items and uses a 0-to-4 rating scale (higher scores indicate more mood disturbance) to examine negative mood states (anger, confusion, depression, fatigue, and tension) and positive mood states (vigor and friendliness).
Social support was multidimensional feelings concerning social support measured by the Multidimensional Scale of Perceived Social Support,19 which has high internal consistency (α = .90). The Multidimensional Scale of Perceived Social Support consisted of 12 items and uses a 1-to-7 rating scale (higher scores indicate more social support) to measure the support from family, friends, and significant others.
Postoperative symptoms and social support were available in Thai language. The frailty and mood states questionnaires were translated into Thai language using a back-translation technique.20 Researchers selected 2 translators who were fluent in both English and Thai, and had experience of at least 5 years in neurological nursing. The first person translated the instruments from English to Thai, and then the second person blindly translated them from Thai to English. The original and translated versions were sent back to then instrument developer for translation quality checking. Then, the instruments were tested with 30 postoperative brain tumor patients who had the same qualifications as the sample before implementing the study.
The research project was approved by the institutional review board. Researchers selected participants who were eligible with inclusion criteria and then introduced themselves and explained study objectives. After participants agreed and signed the informed consents, researchers allowed participants 30 to 45 minutes to complete the questionnaire. Descriptive statistics was used to present the demographics and clinical status of participants including frequency with percentage for nominal and ordinal data, and mean with standard deviation (mean [SD]) for interval and ratio data. Pearson correlation and multiple linear regression were used to examine the relationship among demographic data, clinical characteristics, postoperative symptoms, mood states, social support, and frailty. All data were analyzed using SPSS version 25, and statistical significance was accepted as a P value < .05.
Most of the sample was female (72.9%) with a mean age of 51.7 (13.9) years. Most of the sample was Buddhist and married, had a primary level of education, and was unemployed. Furthermore, most of them (65.9%) had an income of less than 20 000 baht (1 US = 34 THB). Almost half (45.9%) had universal health coverage, and almost all of them (97.6%) had a relative as the primary caregiver.
Most of the participants (71.8%) were given a diagnosis of nonmalignant tumors. The most common type of brain tumor was meningioma. Almost three-quarters (74.1%) had a craniotomy with tumor removal, and most of them (68.2%) had a craniotomy with tumor removal for the first time. The average duration from the beginning of illness to the date of treatment was 209.8 (243.4) days. In addition, the average time after surgery to the data collection date was 3.0 (1.3) days.
The average postoperative symptom score was 69.2 (38.0). The most encountered postoperative symptoms were pain, followed by fatigue, drowsiness (sleepiness), dry mouth, and reduced visibility. The average total mood disturbance score was 18.8 (22.2). When considered by dimension of questions, the positive mood state of vigor-activity had the highest mean score of 9.8 (4.4), whereas the negative mood state of fatigue-inertia had the highest mean score of 7.6 (5.6). Then, the mean social support score was 61.3 (12.2), with the highest support from families. The average frailty score was 2.1 (1.8), as shown in Supplemental Digital Content 1, available at https://links.lww.com/JNN/A432.
Mood state was positively correlated with frailty at a medium level (r = 0.448, P < .01), meaning patients with a highly disturbed mood state after craniotomy were correlated with increased frailty. Postoperative symptoms were positively correlated with frailty at a medium level (r = 0.410, P < .01), meaning patients with high postoperative symptom severity were correlated with increased frailty. Social support was not correlated with frailty. However, postoperative symptoms were found to be positively correlated with mood states at a high level (r = 0.534, P < .01). Postoperative symptom severity may be a cause of mood state changes, as shown in Table 1.
TABLE 1 -
The Correlation Between Postoperative Symptoms, Mood States, Social Support
, and Frailty (N = 85)
Note. 1, postoperative symptom; 2, mood state; 3, social support; 4, frailty.
aThe relationship is significant at P < .01.
Linear regression was used with forward selection technique to examine the predictors of frailty. Postoperative symptoms, mood states, age, brain tumor type, and income were able to explain the variance of frailty in brain tumor patients after craniotomy at 40.3% with statistical significance (F = 10.647, P < .01, R2 = 0.403, adjusted R2 = 0.365). Frailty increased by 0.013 points for a 1-point increase of postoperative symptoms when adjusted for mood states, age, brain tumor types, and income (B = 0.013, P = .008). Frailty increased by 0.024 points for a 1-point increase of mood states when adjusted for postoperative symptoms, age, brain tumor types, and income (B = 0.024, P = .006). Frailty increased by 0.030 points for a 1-year increase of age when adjusted for postoperative symptoms, mood states, brain tumor types, and income (B = 0.030, P = .013). Frailty in patients given a diagnosis of a malignant brain tumor was higher than in patients given a diagnosis of a benign brain tumor by 0.817 points when adjusted for postoperative symptoms, mood states, age, and income (B = 0.817, P = .029). Frailty decreased by 0.000019 points for each baht increase of income when adjusted for postoperative symptoms, mood states, brain tumor types, and age (B = 0.000019, P = .020), as shown in Table 2.
TABLE 2 -
Predictors of Frailty Among Patients With Brain Tumor After Craniotomy With Tumor Removal (N = 85)
|Type of tumora
Note. R = 0.634, R2 = 0.403, F = 10.647, P < .01.
Abbreviations: B, unstandardized beta; SE, standard error; β, standardized beta.
aComparison between malignant and benign tumors.
Demographic findings from this study were consistent with previous studies. For instance, brain tumor incidence was found to be higher in women compared with men, and meningioma was the most common type of tumor in patients with brain tumors.1 Most Thai patients with brain tumors were female and married, were educated at the primary education level, and had universal health coverage.21 Moreover, primary caregivers were relatives, and patients had a low income. Low income may have been caused by pathologies of the disease and treatment, causing patients to have less ability to work and perform activities of daily living with impairments of physical function,21 preventing patients from returning to their usual daily lives.
The most severe postoperative symptom after brain tumor surgery was pain, which concurred with a previous study among pituitary macroadenoma patients,22 because surgery caused partial damage to brain tissues such as trauma to the meninges, brain matter, capillaries, and nerves that trigger nociceptors. Postoperative pain will ease after receiving pain medications such as acetaminophen and morphine. If traditional pain management could not control the pain, healthcare providers should consider alternative treatment to avoid the adverse effects of narcotic medication.23 This was different from headaches in the preoperative period because of increased pressure in the cranium from brain tumor growth, causing tumors to take up more space in the cranium24 and consistent with previous studies.21 Then, mood disturbance in this study was higher than in the previous study in Thailand that collected data at 2 weeks after surgery.21 This study was conducted within 1 week after surgery so unpleasant physical symptoms may influence the mood states of patients in this phase.
For social support, most of the patients received the most social support from family, followed by social support from friends and social support from significant others. Patients who were given a diagnosis of brain tumors needed surgical treatment and management with uncertain symptoms so family members played a major role in supporting individuals to manage their illness.25,26 Then, most of the patients were frail during the postoperative phase because of pathologies of the disease and the alteration of the brain from surgery.14 Moreover, the findings concurred with previous studies that increased frailty was associated with neurological impairments, physical function, and unpleasant treatment outcomes.7,12,27,28 However, social support could develop caregivers' burden. Therefore, healthcare providers should introduce health benefits and social networks for caregivers to strengthen the support for patients.29
The findings supported the hypothesis that postoperative symptoms and mood states were able to predict frailty in brain tumor patients after craniotomy. Moreover, age, income, and brain tumor type were able to predict frailty in brain tumor patients after craniotomy. Postoperative symptoms could indicate frailty to occur in brain tumor patients after surgery. Therefore, after craniotomy, postoperative symptoms occurred and patients had less ability to perform activities of daily living, thereby enabling prediction of frailty in brain tumor patients after craniotomy. Then, psychological symptoms could influence frailty outcomes in patients with cardiovascular diseases.9,30 Therefore, patients with brain tumors after craniotomy may be confronted with psychological alteration, which could induce frailty.
In terms of age, patients at an older age had more frailty27,28 and patients at older ages were more likely to become more frail.7 Then, type of brain tumor was another significant predictor of frailty. Frailty was likely to occur in patients with malignant brain tumors than in those with benign brain tumors,28 whereas tumor type and frailty were able to predict likelihood of unpleasant treatment outcomes and rehospitalization.14 Next, income of patients could also predict frailty. This can be explained by the theory of unpleasant symptoms,31 in which income was a situational factor contributing to unpleasant symptoms, and the result from the symptoms was frailty, meaning patients with a lower income were found to have more frailty.
This study has some limitations. First, this study collected data at only 1 university hospital in Thailand; therefore, the findings may not be generalizable to other hospital levels (ie, tertiary, secondary) as well as other countries with different sociocultural characteristics. Second, this study was a cross-sectional study, so researchers may not assume a causal relationship or the cause between each independent variable with frailty. Third, this study included only patients with full consciousness, so the findings may be different in patients with an alteration of consciousness.
Postoperative symptoms and psychological symptoms were associated with frailty, so healthcare providers should plan for discharge planning including assessment and developing the intervention for managing postoperative symptoms and psychological symptoms to promote recovery from frailty that generally occurs after brain tumor surgery. Moreover, nurses should screen for risk factors particularly age, income, and types of brain tumor to prevent frailty, which may commonly occur in patients with such risk factors.
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