Guillain-Barré Syndrome: Incidence and In-hospital Mortality
Abstract & Commentary
By Michael Rubin, MD, FRCP(C), Professor of Clinical Neurology, Weill Cornell Medical College, New York, NY. Dr. Rubin reports that he receives grant/research support from Pfizer and that he is on the speaker's bureau for Athena Diagnostics. This article originally appeared in the June 2008 issue of Neurology Alert. It was edited by Matthew Fink, MD, and peer reviewed by M. Flint Beal, MD.
Synopsis: Guillain-Barré syndrome remains a common and serious cause of acute neuropathy in the elderly.
Source: Alshekhlee A, et al. Guillain-Barré syndrome: incidence and mortality rates in US hospitals. Neurology 2008; 70:1608-1613.
In this observational study, Guillain-Barré Syndrome (GBS) incidence, in-hospital mortality, and predictors of death were calculated using a sample of 6101 patients who had an admission diagnosis of GBS, were age 18 or older, hospitalized in the United States, and identified through the Nationwide Inpatient Sample (NIS) database spanning five years from 2000-2004. Sponsored by the Agency for Healthcare Research and Quality, the health-services research arm of the US Department of Health and Human Services and the nation's leading Federal agency for research on health care quality, costs, outcomes, and patient safety, NIS collects information on inpatient stays from approximately 1000 hospitals, sampled to approximate a 20% stratified sample of US community hospitals. In this study, patients were excluded if their admitting diagnosis was chronic inflammatory demyelinating polyneuropathy, critical illness polyneuropathy or myopathy, polyneuropathy due to other causes (eg, porphyria), poliomyelitis, myasthenia gravis, transverse myelitis, alcohol or other drug intoxication, or poisoning. Patients also were excluded who had missing data, including age, sex, or death status; patients transferred between acute care hospitals to avoid repetition of data; patients whose final hospital charge was less than $100.00 (on the assumption that the admitting diagnosis in this instance was likely in error); and, due to the capped duration-of-stay rule, patients whose hospitalization exceeded 365 days. Student's t test, Wilcoxon rank sum, chi-square tests, and the Cochran-Armitage and Hosmer and Lemeshow tests provided statistical analysis. Significance was set at P < 0.01.
Of the 6101 patients, 1145 were excluded, most often due to having been a patient transferred between hospitals. Among the remaining 4954 patients included in the study, the mean age was 48.4 years; 55.3% were men. GBS incidence rate varied between 1.65 and 1.79 per 100,000, and did not change significantly over the study period. Median hospital stay was 7 days and had a median cost of $37,813.00; 55.3% of patients were discharged directly home. Pulmonary complications were most common (11.3%); 9.1% of patients required endotracheal intubation. Cardiac, thrombotic, and septic complications were less frequent but predicted in-hospital mortality by an odds ratio of 3.5 (cardiac), 3.64 (infection), and 5.09 (intubation). Mortality was consistent at 2.58% during hospitalization, higher (13.7%) among those requiring intubation, but only 1.46% in the non-intubated group. Mortality was higher among those older than age 50 (odds ratio 4.04), and increased further in the older-than-age 75 group (odds ratio 10.8).
Commentary
Guillain-Barré syndrome (GBS) demonstrates a bimodal age distribution, with one peak in the younger (15-34 years) and another in the older population (60-74 years). Impaired immunosuppression may be responsible in the latter, making GBS the third most common neuropathy in those older than age 65.1 Disease severity is similar in both age-groups, but the time-to-peak severity is shorter and antecedent illness in less frequent in the elderly.2 Ophthalmoplegia and facial weakness also are less common, but the axonal variant may occur in up to 40% of older GBS patients.3 Relapse rate is not age-dependent, but length of hospital stay is. Plasmapheresis and intravenous immunoglobulin remain the treatment standards, but the latter is simpler and associated with fewer complications, making it the preferred choice for the older patient.
References
1. George J, et al. Causes of polyneuropathy in the elderly. Age Ageing 1986;15:247-249.
2. Sridharan GV, et al. Guillain-Barré syndrome in the elderly. A retrospective comparative study. Gerontology 1993;39:170-175.
3. Leung SS. Guillain-Barré syndrome in elderly people. J Am Geriatr Soc 2008;56:381-382.
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