Association of Older Age and Frailty With Depression and Postoperative Regret About Major Head and Neck Surgery

Association of Older Age and Frailty With Depression and Postoperative Regret About Major Head and Neck Surgery: This cohort study assesses whether age and frailty are associated with preoperative and/or worsening postoperative depression and postoperative decision regret in patients undergoing major head and neck surgery and identifies additional factors associated with depression and decision regret.






Carissa M. Thomas, MD, PhD1,2; Michael C. Sklar, MD3; Jie Su, MSc4; et alWei Xu, PhD4,5; John R. de Almeida, MD, MSc1,2; Patrick Gullane, MB1,2; Ralph Gilbert, MD1,2; Dale Brown, MB1,2; Jonathan Irish, MD, MSc1,2; Shabbir M. H. Alibhai, MD, MSc6,7,8; David P. Goldstein, MD, MSc1,2

Author Affiliations

1Department of Otolaryngology–Head and Neck Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada

2Department of Surgical Oncology, Princess Margaret Cancer Center, University Health Network, Toronto, Ontario, Canada

3Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada

4Department of Biostatistics, Princess Margaret Cancer Centre/University Health Network, Toronto, Ontario, Canada

5Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada

6Department of Medicine, University of Toronto, Toronto, Ontario, Canada

7Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada

8Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada

JAMA Otolaryngol Head Neck Surg. 2019;145(12):1170-1178. doi:10.1001/jamaoto.2019.3020

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Key Points

Question  Do elderly or frail patients with head and neck cancer have worse depression and higher rates of decision regret after surgery?



Findings  In this cohort study, the prevalence of preoperative moderate to severe depression was 9.6% and the prevalence of moderate to severe decision regret was 26.7%. Elderly patients (≥65 years) did not have increased depression or decision regret; however, higher frailty scores are associated with depression and worse depression is associated with decision regret.



Meaning  Identifying at-risk populations and understanding factors associated with depression and decision regret allows for targeted preoperative and postoperative treatment and counseling.



Abstract

Importance  Clinicians should understand the prevalence of depression and decision regret in patients with head and neck cancer and whether these factors differ with age or frailty.



Objectives  To assess whether age and frailty are associated with preoperative and/or worsening postoperative depression and postoperative decision regret in patients undergoing major head and neck surgery and to identify additional factors associated with depression and decision regret.



Design, Setting, and Participants  This prospective cohort study was conducted at a single institution, with patients aged 50 years or older undergoing major head and neck surgery recruited from December 1, 2011, to April 30, 2014. Statistical analysis was performed from July 1, 2018, to June 30, 2019.



Main Outcomes and Measures  Frailty, functional, and geriatric depression assessments were completed before surgery and 3, 6, and 12 months after surgery. Decision regret assessment was completed 6 months after surgery. The prevalence of depression and decision regret was determined by age group. Change in depression over time was compared between age groups using a linear-effects model. Variables potentially associated with moderate to severe depression and decision regret were analyzed using a logistic regression model.



Results  The study included 274 patients (68 women and 206 men; mean [SD] age, 67.8 [9.5] years). Of these, 105 (38.3%) were 50 to 64 years of age and 169 (61.7%) were 65 years or older. The rate of preoperative moderate to severe depression was 9.6% (21 of 219), with no difference between younger and older adult cohorts. For both age groups, depression scores increased in the postoperative period from baseline to 6 months. At 12 months, there was a difference in depression scores between the younger and older adult cohort (4.8 [4.6] vs 3.1 [3.6]). A higher preoperative Fried Frailty Index score (odds ratio, 2.58 [95% CI, 1.63-4.06]) was associated with preoperative moderate to severe depression. For all patients, the mean Decision Regret Scale score was 18.2 (range, 0-95), and 26.7% of patients (48 of 180) had moderate to severe regret. There was no difference in Decision Regret Scale scores between younger and older patients. Preoperative depression but not frailty is associated with postoperative moderate to severe decision regret (odds ratio, 1.17 [95% CI, 1.06-1.28]).



Conclusions and Relevance  In this cohort study, there was no difference based on age in the prevalence of moderate to severe depression or decision regret. A higher preoperative frailty score was associated with depression but not decision regret. Preoperative depression was the only factor associated with moderate to severe decision regret on multivariate analysis. Understanding the prevalence of and factors associated with moderate to severe depression and decision regret may aid in identifying patients who would benefit from more extensive preoperative counseling and preoperative and postoperative multispecialty assessment and treatment.