Perioperative mental health intervention for older adults undergoing hip and knee arthroplasty for osteoarthritis

摘要/项目摘要-项目1 到2030年，400万老年人将接受选择性全髋关节或膝关节置换术(THA/TKA)，其中 旨在减轻这一年龄段疼痛和身体残疾的常见择期外科手术。精神性 健康问题在这些患者中非常普遍，20%-30%的人报告说有明显的焦虑症状 以及手术前和术后的抑郁。抑郁和焦虑通过(I)使THA/TKA预后恶化 减少对康复的参与，从而阻碍康复；(2)增加对疼痛的敏感性， 增加翻修手术的风险并增加长期使用阿片类药物的可能性，以及(3)提高 有精神错乱和神经认知恢复延迟的风险。尽管记录了对个人和我们的 在卫生保健系统中，治疗焦虑和抑郁的有效干预措施尚未应用于 为接受全髋关节置换术/全膝关节置换术的老年人评估。在这项提案中，我们将优化和测试一种药理 和行为干预捆绑包，适用于接受骨关节炎全关节置换术的老年患者， 临床上有明显的抑郁和焦虑症状。在这项建议中，我们将建立围手术期的心理状态 医疗保健捆绑包包括：(1)应用经过验证的行为干预，即行为激活(BA)， 基于患者偏好和需求的策略；以及(2)药物优化和停药(MOD)， 有针对性地优化抗抑郁药物的剂量，停止有害或无效的药物。 目标1(适应)：在协作规划方法的指导下，我们将适应、制定和实施 老年人接受大型骨科手术的最佳围手术期心理健康干预包 程序。通过利益相关者的输入，我们将开发并迭代地调整行为和药物 用于在该人群中实施的优化干预捆绑包。在最初的协议开发之后， 通过治疗开发试验，我们将通过互动反馈反复优化干预 来自正在接受主要骨科干预的65岁以上患者和其他利益相关者，注意到 项目完成的障碍和促进者。目标2(测试)：使用混合型1型随机对照 试验设计，我们将比较干预捆绑和常规护理在减轻症状方面的有效性 在接受骨科手术的老年患者中抑郁和焦虑的发生率。为此，100名患者接受了 抑郁和焦虑的症状将被随机分配到药物和行为 干预捆绑或常规护理。术前抑郁和焦虑与许多不良反应有关 手术后的结果，包括并发症、跌倒、精神错乱和疼痛。因此，药物优化， 全关节手术中老年患者抑郁和焦虑的停药和行为治疗 关节成形术可以改善抑郁和焦虑的症状以及其他重要的术后症状 结果。

Abstract/Project Summary – PROJECT 1 By 2030, 4 million older adults will undergo elective total hip or knee arthroplasty (THA/TKA), the most common elective surgical procedures intended to mitigate pain and physical disability in this age group. Mental health problems are highly prevalent in these patients, with 20-30% reporting substantial symptoms of anxiety and depression both pre- and post-operatively. Depression and anxiety worsen THA/TKA outcomes by (i) reducing participation in rehabilitation, thereby impeding recovery, (ii) heightening susceptibility to pain which increases the risk of revision surgery and increases the likelihood of prolonged opioid use, and (iii) raising the risk for delirium and delayed neurocognitive recovery. Despite the documented impact on individuals and our health care system, effective interventions that treat anxiety and depression have not been applied to and evaluated for older adults undergoing THA/TKA. In this proposal, we will optimize and test a pharmacological and behavioral intervention bundle for older patients undergoing total joint arthroplasty for osteoarthritis, with clinically significant depressive and anxiety symptoms. In this proposal, we will institute a perioperative mental healthcare bundle including: (1) applying a proven behavioral intervention, behavioral activation (BA), with strategies based on patient preferences and needs; and (2) medication optimization and deprescribing (MOD), targeting to optimize dosages of anti-depressant medications, and stopping harmful or ineffective medications. Aim 1 (Adaptation): Informed by a collaborative planning approach, we will adapt, develop and implement an optimal perioperative mental health intervention bundle for older adults undergoing major orthopedic procedures. Through stakeholder input, we will develop and iteratively adapt a behavioral and medication optimization intervention bundle for implementation in this population. Following initial protocol development, through treatment development trials, we will iteratively optimize the intervention through interactive feedback from patients over the age of 65 undergoing major orthopedic intervention, and other stakeholders, noting barriers and facilitators to program completion. Aim 2 (Testing): Using a hybrid Type 1 randomized controlled trial design, we will compare the effectiveness of the intervention bundle with usual care in reducing symptoms of depression and anxiety in older patients undergoing orthopedic surgery. For this aim, 100 patients with symptoms of depression and anxiety will be randomly assigned to the pharmacological and behavioral intervention bundle or usual care. Pre-operative depression and anxiety are associated with a host of adverse outcomes after surgery, including complications, falls, delirium, and pain. Thus, medication optimization, deprescribing, and behavioral treatment of depression and anxiety in older adults undergoing total joint arthroplasty may improve symptoms of depression and anxiety as well as other important post-operative outcomes.