Objective To explore the predictive value of albumin, hemoglobin and multifactorial model for poor postoperative prognosis in elderly patients with meningioma. Methods A retrospective analysis was conducted on 253 elderly patients who underwent meningioma surgery and were transferred to the neurosurgical intensive care unit (NICU) at General Hospital of Northern Theater Command from January 2019 to September 2021, serving as the modeling cohort. Another 227 elderly patients who were treated in NICU after meningioma surgery from November 2021 to June 2023 were used as the validation cohort. Patients in the modeling cohort were categorized into good prognosis group [Glasgow Coma Scale (GCS) score>7, n=161] and poor prognosis group (GCS≤7, n=92) based on the GCS. Univariate and multifactorial logistic regression analyses were performed on the modeling cohort to identify independent risk factors, and a multifactorial model for predicting poor postoperative prognosis in elderly patients with meningioma was constructed based on these factors. The predictive efficacy and accuracy of the model were evaluated using the area under the receiver operating characteristic (ROC) curve (AUC), sensitivity, specificity, Hosmer-Lemeshow goodness-of-fit test, and calibration curves. The predictive value of postoperative albumin, hemoglobin, and the multifactorial models for postoperative prognosis in elderly meningioma patients was assessed using restricted cubic spline modeling (RCS), decision curves (DCA), and validated using an external validation cohort to assess the stability of the model. Results Meningioma WHO grade Ⅱ and Ⅲ (OR=3.994, 95%CI 1.963-8.126), postoperative hypoalbuminemia (OR=2.194, 95%CI 1.079-4.462), and postoperative anemia (OR=2.117, 95%CI 1.096-4.089) were identified as independent risk factors for poor postoperative prognosis in elderly meningioma patients (P<0.05), while the use of analgesic/sedative medications was a protective factor (OR=0.388, 95%CI 0.201-0.748, P<0.05). The Hosmer-Lemeshow test indicated that the constructed multifactorial model had a good fit accuracy (P=0.161). The AUC for predicting poor postoperative prognosis in elderly meningioma patients for postoperative albumin and hemoglobin were 0.545 (95%CI 0.472-0.617) and 0.632 (95%CI 0.561-0.702), respectively, and showed a nonlinear dose-response relationship with prognosis (P<0.01). DCA analysis results showed that the net benefit rate of multifactorial model was higher than that of postoperative albumin and hemoglobin when the threshold probabilities were between 0.10 and 0.90. The AUC for predicting postoperative prognosis in the elderly meningioma patients in the modeling and validation cohorts were 0.810 and 0.819, respectively, and their calibration curves suggested good discrimination and accuracy. Conclusions Meningioma WHO grades Ⅱ and Ⅲ, postoperative anemia and hypoalbuminemia are independent risk factors for poor postoperative prognosis in elderly meningioma patients, while the use of analgesic/sedative drugs is a protective factor. The multifactorial model constructed based on these factors has a good predictive efficacy and credibility, and can be used as a reference for clinical decision-making.