Skip to main content

Frailty concept in Africa neurosurgical practice: a prospective review


Neurosurgical management of older patients is very complex and delicate; efforts are being made in identifying groups of older patients at risk of poor surgical outcomes before the surgery, making frailty an important concept in risk Identification and postoperative outcome assessment of older patients in the ever-changing neurosurgical world. It's of great importance for the concept of frailty to be adopted in Africa's neurosurgical practice in other to optimize the outcomes and improve the efficiency of neurosurgery in the older patients whose population is expanding, forming a great quota of people using neurosurgical services in Africa. This article looks into the importance and challenges of frailty studies in African neurosurgical practice which mainly are the longer length of time in carrying out such studies; reduces manpower, lack of availability of specialized equipment in standardizing the assessment, and others; makes recommendations on ways to ease its adoption such as funding frailty research and creation of population-specific frailty assessment tools among others.


A condition or syndrome that results from a multisystem reduction in reserve capacity to the extent that several physiological systems are close to or pass the threshold of symptomatic clinical failure is referred to as frailty, which is a state of increased vulnerability to adverse outcomes [1, 2]. Frailty is a collection of subthreshold decrements that have an impact on multiple physiological systems and make a person more vulnerable [3]. The common focal idea about fragility is of a more established individual who is at the uplifted hazard of unfavorable well-being status change [4]. It’s a multifaceted idea that thinks about the complicated exchange of physical, mental, social, and ecological elements [5]. According to Fried et al., frailty can be recognized based on the presence of three or more core elements such as poor endurance, weakness, tiredness, low level of physical activities, and slow gait [6]. One or two of these features indicate a precursor state, three or more of these features indicate frailty, and none indicate no frailty [7]. Frailty is a concept that has been used to determine surgical outcomes in older patients; therefore, it becomes a crucial factor in Africa's practice of neurological surgery, as a result of increased life expectancy in the continent and increase usage of neurosurgical services [8,9,10,11]

With expanding population of elderly people in the world and Africa, improving neurosurgical care to this age group becomes paramount, and frailty studies are important tools in ensuring improved neurosurgical service delivery to elderly people in Africa. Wojda et al. reported an increase in the population of elderly patient that are presenting in the accident and emergencies in sub-Saharan Africa over the period of 1989–2014, as seen in Fig. 1 [12]. A study using Hopkins Frailty Score that was developed by Makery et al. as a standardized, verified perioperative risk assessment tool for surgical patients found that frailty independently predicts the discharge predisposition, postoperative complications, and length of stay in patients undergoing surgery for brain tumor resection [13,14,15]

Fig. 1
figure 1

Adopted from Wodja et al. 2016 [12]

Graphical representation of the increasing proportion of patients defined as elderly (Y-axis) in the literature reports from sub-Saharan Africa, based on accident and emergency literature between 1990 and 2014 (X-axis). Individual reports are each represented by “X”, with the dashed heavy black line showing the third-degree polynomial model of the overall composite trend.

This article is aimed at comparing the state of frailty in the Africa neurosurgical practice with practice. It is a review of studies that have been done on frailty concept in neurosurgery globally, comparing it with the state of neurosurgical practice in Africa, how well as frailty being incorporated and making recommendation on ways of improving so as to meet global standards. Due to the limited availability of research articles reporting the frailty concept in neurosurgery in Africa, this article has the weakness of basing it judgment based on the little available researches.

Importance of frailty in Africa neurosurgical practice

Frailty is found to be an important risk assessor in determining and improving the outcome of patients going for neurological surgeries such as brain tumor resection, deep brain stimulations, decompressive surgeries, and spinal surgeries in the Western world [16,17,18,19,20]. This concept, if adapted into neurosurgical practice in Africa, will have positive effects on various neurosurgical procedures through the identification of high-risk patients whose physiological states are not fit for the surgery, thereby reducing the postoperative mortalities and morbidities. States and outcomes of neurosurgical procedures in Africa are relatively lagging in the number of surgeons, available equipment and technology, and preoperative, perioperative, and postoperative management when compared with Western countries such as the USA, UK, Canada, and others as reported in different studies [21,22,23].

Frailty studies have important roles in optimizing neurosurgical outcomes in Africa, as the frailty index was found to be useful in determining perioperative morbidity [24]. It’s therefore important that research that focuses on generating a frailty index that will be specific for patients in different neurosurgical facilities across the continent be carried out to serve as guides for neurosurgeons in carefully selecting patients for surgeries and also preoperative counseling and consent taking.

Challenges of frailty studies in Africa neurosurgical practice

There are several challenges to frailty studies in Africa, which include the length of time in completing frailty assessment; it takes a longer period and close patient monitoring to carry out such studies which makes it quite difficult in Africa where there is little compliance to clinic visit especially when it comes to postoperative monitoring. In general, newer frailty assessment tools are designed to be shorter in duration and more conveniently performed in an outpatient preoperative clinic [25]. At this time, tools such as the Physical Frailty Phenotype require patient participation, specialized equipment, staff training for standardized assessment, and additional time to perform the physical measurements [7, 25]. Also, the reduced ratio of practicing neurosurgeons to the patient population in the continent makes patient participation in frailty studies quite difficult; lack of availability of specialized equipment in standardizing this assessment is also an important challenge to frailty studies in Africa. The poor state of medical records in Africa also poses a challenge to frailty research; some frailty assessment tools are based on electronic medical records and databases which are not fully implemented in Africa [25, 26].


Frailty risk assessment studies should be encouraged in Africa especially in delicate medical practices such as neurosurgery to help in peri- and postoperative risk stratification and outcome improvement. Neurosurgical staff should be trained in carrying out frailty assessment and research, and specialized equipment in aiding such assessment should be provided in various centers. Frailty research in neurosurgical patients should be funded by governmental and non-governmental organizations. The African Center for Disease Control and various National Centers for Disease Control should work on creating an easy-access database for neurosurgical patients that will aid frailty research and assessment. Frailty assessment tools that will be specific to African patients should be developed.


Frailty is an important concept in the ever-changing medical world that has an important role in determining surgical outcomes. Frailty concept should be introduced to neurosurgical practice in Africa, as this will improve the quality of services provided and also the outcome of procedure; frailty index will help in prognosticating outcomes of surgeries, selection of patients that are fit for surgeries, and educating patients when taking consents for procedures. Efforts should be put in place to see to its adoption in African neurosurgical practices as a current trend in improving neurosurgical outcomes.

Availability of data and materials

Extracted data from the studies included in this review are presented in the Cost Table.

Code availability

Not applicable.


  1. Frieswijk N, Buunk BP, Steverink N, Slaets JP. The effect of social comparison information on the life satisfaction of frail older persons. Psychol Aging. 2004;19(1):183–90.

    Article  PubMed  Google Scholar 

  2. Campbell AJ, Buchner DM. Unstable disability and the fluctuations of frailty. Age Ageing. 1997;26(4):315–8.

    Article  CAS  PubMed  Google Scholar 

  3. Slaets JP. Vulnerability in the elderly: frailty. Med Clin N Am. 2006;90(4):593–601.

    Article  PubMed  Google Scholar 

  4. Martin FC, Brighton P. Frailty: different tools for different purposes? Age Ageing. 2008;37(2):129–31.

    Article  PubMed  Google Scholar 

  5. Markle-Reid M, Browne G. Conceptualizations of frailty in relation to older adults. J Adv Nurs. 2003;44(1):58–68.

    Article  PubMed  Google Scholar 

  6. Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol Ser B Biol Sci Med Sci. 2004;59(3):255–63.

    Article  Google Scholar 

  7. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA, Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol Ser A Biol Sci Med Sci. 2001;56(3):M146–56.

    Article  CAS  Google Scholar 

  8. Hall DE, Arya S, Schmid KK, Blaser C, Carlson MA, Bailey TL, Purviance G, Bockman T, Lynch TG, Johanning J. Development and Initial Validation of the Risk Analysis Index for Measuring Frailty in Surgical Populations. JAMA Surg. 2017;152(2):175–82.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Angell B, Sanuade O, Adetifa IMO, Okeke IN, Adamu AL, Aliyu MH, Ameh EA, Kyari F, Gadanya MA, Mabayoje DA, Yinka-Ogunleye A, Oni T, Jalo RI, Tsiga-Ahmed FI, Dalglish SL, Abimbola S, Colbourn T, Onwujekwe O, Owoaje ET, Aliyu G, et al. Population health outcomes in Nigeria compared with other west African countries, 1998–2019: a systematic analysis for the Global Burden of Disease Study. Lancet. 2022;399(10330):1117–29.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Aderinto N, Opanike J, Oladipo E, Olakanmi D, Adepoju O. Accessing neurosurgical services in Africa: efforts, challenges, and recommendation. Int J Surg Global Health. 2022;5(6):e90.

    Article  Google Scholar 

  11. Aderinto N, Alare K, AbdulBasit OM, Edun M, Ogunleke P. Prevalence of neuroinfectious diseases and outcomes in Africa. Int J Surg Global Health. 2023;6(2):e104.

    Article  Google Scholar 

  12. Wojda TR, Cornejo K, Valenza PL, Carolan G, Sharpe RP, Mira AE, Galwankar SC, Stawicki SP. Medical demographics in sub-Saharan Africa: Does the proportion of elderly patients in accident and emergency units mirror life expectancy trends? J Emerg Trauma Shock. 2016;9(3):122–5.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, Takenaga R, Devgan L, Holzmueller CG, Tian J, Fried LP. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210(6):901–8.

    Article  PubMed  Google Scholar 

  14. Harland TA, Wang M, Gunaydin D, Fringuello A, Freeman J, Hosokawa PW, Ormond DR. Frailty as a predictor of neurosurgical outcomes in brain tumor patients. World Neurosurg. 2020;133:e813–8.

    Article  PubMed  Google Scholar 

  15. Ugare GU, Ndifon W, Bassey IA, Oyo-Ita AE, Egba RN, Asuquo M, Udosen AM. Epidemiology of death in the emergency department of a tertiary health centre south-south of Nigeria. Afr Health Sci. 2012;12(4):530–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Thommen R, Kazim SF, Rumalla K, Kassicieh AJ, Kalakoti P, Schmidt MH, McKee RG, Hall DE, Miskimins RJ, Bowers CA. Preoperative frailty measured by risk analysis index predicts complications and poor discharge outcomes after Brain Tumor Resection in a large multi-center analysis. J Neurooncol. 2022;160(2):285–97.

    Article  PubMed  Google Scholar 

  17. Owodunni OP, Roster K, Varela S, Kazim SF, Okakpu U, Tarawneh OH, Thommen R, Kogan M, Sheehan J, Mckee R, Deligtisch A, Schmidt MH, Bowers CA. Preoperative frailty risk in deep brain stimulation patients: Risk analysis index predicts Clavien-Dindo IV complications. Clin Neurol Neurosurg. 2023;226:107616.

    Article  PubMed  Google Scholar 

  18. Kassicieh AJ, Estes EM, Rumalla K, Kazim SF, McKee RG, Schmidt MH, Bowers CA. Thirty-day outcomes for suboccipital decompression in adults with Chiari malformation type I: a frailty-driven perspective from the American College of Surgeons National Surgical Quality Improvement Program. Neurosurg Focus. 2023;54(3):E6.

    Article  PubMed  Google Scholar 

  19. Kassicieh AJ, Rumalla K, Segura AC, Kazim SF, Vellek J, Schmidt MH, Shin PC, Bowers CA. Endoscopic and nonendoscopic approaches to single-level lumbar spine decompression: propensity score-matched comparative analysis and frailty-driven predictive model. Neurospine. 2023;20(1):119–28.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Owodunni OP, Yocky AG, Courville EN, Peter-Okaka U, Alare KP, Schmidt M, Alunday R, Greene-Chandos D, Bowers CA. A comprehensive analysis of the triad of frailty, aging, and obesity in spine surgery: the risk analysis index predicted 30-day mortality with superior discrimination. Spine J Off J N Am Spine Soc. 2023;23:1778–89.

    Article  Google Scholar 

  21. Boever J, Weber T, Krause EA, Mussa JA, Demissie YG, Gebremdihen AT, Mesfin FB. Neurosurgical patients’ experiences and surgical outcomes among single tertiary hospitals in Ethiopia and the United States. Cureus. 2022;14(2):e22035.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Dada OE, Karekezi C, Mbangtang CB, Chellunga ES, Mbaye T, Konan L, Adeniran Bankole ND, Merci Kabulo KD, Hugues Dokponou YC, Ghomsi NC, Negida A, Nguembu S, Thango N, Cheserem B, Kamabu LK, Alalade AF, Esene I, Kanmounye US. State of neurosurgical education in Africa: a narrative review. World Neurosurg. 2021;151:172–81.

    Article  PubMed  Google Scholar 

  23. Xu LW, Vaca SD, Nalwanga J, Muhumuza C, Vail D, Lerman BJ, Kiryabwire J, Ssenyonjo H, Mukasa J, Muhumuza M, Haglund MM, Grant G. Life after the neurosurgical ward in Sub-Saharan Africa: neurosurgical treatment and outpatient outcomes in Uganda. World Neurosurg. 2018;113:e153–60.

    Article  PubMed  Google Scholar 

  24. Gu C, Lu A, Lei C, et al. Frailty index is useful for predicting postoperative morbidity in older patients undergoing gastrointestinal surgery: a prospective cohort study. BMC Surg. 2018;22:57.

    Article  Google Scholar 

  25. Nidadavolu LS, Ehrlich AL, Sieber FE, Oh ES. Preoperative evaluation of the frail patient. Anesth Analg. 2022;130(6):1493–503.

    Article  Google Scholar 

  26. Odekunle FF, Odekunle RO, Shankar S. Why sub-Saharan Africa lags in electronic health record adoption and possible strategies to increase its adoption in this region. Int J Health Sci. 2017;11(4):59–64.

    Google Scholar 

Download references


We acknowledge our teacher Dr Stanley Nnara a senior registrar Neurosurgery Unit, Department Of Surgery, LAUTECH Teaching Hospital, for his guidance on this case.


No financial support was received for this manuscript.

Author information

Authors and Affiliations



K.A. contributed to conceptualization, project administration and writing—review and Designing. K.A., P.O. and O.T. performed collection and assembly of data. K.A., E.A. and H.J. reviewed and edited the final. K.A. and E.A. worked on Fig. 1. H.J., P.O. and O.T. worked on Fig. 1. All authors wrote the manuscript and made final approval of manuscript.

Corresponding author

Correspondence to Kehinde Alare.

Ethics declarations

Ethics approval and consent to participate

Not applicable for this systematic review.

Consent to publication

Not applicable.

Competing interest

The authors declare that they have no conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Alare, K., Jagunmolu, H., Adewuyi, E. et al. Frailty concept in Africa neurosurgical practice: a prospective review. Egypt J Neurosurg 39, 30 (2024).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: