Decision making in chronic subdural haematoma patient referrals in an octogenarian and nonagenarian population – a multi-centre perspective

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BACKGROUND: The incidence of chronic subdural haematoma (CSDH) is rising in the elderly, yet there is limited research focusing on patients aged > 80. In the United Kingdom, the decision to transfer for neurosurgical intervention is dependent upon the acceptance of a CSDH management referral by a tertiary centre. AIMS: This study thus aims to identify key predictors of referral acceptance in octogenarian and nonagenarian age groups, in comparison to the adult population. METHODS: A multi-centre retrospective case series analysis from January 2015 to May 2020 was conducted. Patients were grouped as < 80 ('adult') or > 80 ('ultra-geriatric'), with the latter further subgrouped into 80-89 ('octogenarian'), and ≥ 90 ('nonagenarian'). Multivariable logistic regression assessed age, headache, dementia, motor weakness, midline shift, CSDH size, and premorbid quality of life (QoL) to determine predictors of referral acceptance. RESULTS: With a total of 3002 patient referrals, referral acceptance was significantly higher in adults compared to the ultra-geriatric group (38.1%vs22.4%, p < 0.001) and in octogenarians versus nonagenarians (27.7%vs10.5%, p = 0.036). CSDH size and premorbid QoL were consistent independent predictors across all age groups. In adults, all seven variables were significant predictors. For the ultra-geriatric group, all but headache and dementia were significant. Among octogenarians, motor weakness, midline shift, CSDH size, and premorbid QoL predicted acceptance, while in nonagenarians, only age, CSDH size, and QoL were significant. CONCLUSIONS: We demonstrate the importance of CSDH size and premorbid QoL as independent predictor variables for neurosurgical referral acceptance in all analysed age groups, particularly in the octogenarian and nonagenarian patient population, whilst other variables had variable significance depending upon age group.