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，400万老年人将接受择期全髋关节或膝关节置换术（THA/TKA）， 旨在减轻该年龄组疼痛和身体残疾的常见择期手术。心理 健康问题在这些患者中非常普遍，20-30%的患者报告有严重的焦虑症状 以及手术前后的抑郁抑郁和焦虑通过以下方式恶化THA/TKA结局：（i） 减少参与康复，从而阻碍恢复，（ii）增加对疼痛的敏感性， 增加了翻修手术的风险，并增加了长期使用阿片类药物的可能性，以及（iii）提高了 谵妄和神经认知恢复延迟的风险。尽管有记录的影响，对个人和我们的 在卫生保健系统中，治疗焦虑和抑郁症的有效干预措施尚未应用于 对接受THA/TKA的老年人进行评价。在本提案中，我们将优化和测试一种药理学 和行为干预捆绑，用于接受骨关节炎全关节置换术的老年患者， 临床上显著的抑郁和焦虑症状。在这个建议中，我们将建立一个围手术期的精神 医疗保健包包括：（1）应用经过验证的行为干预，行为激活（BA）， 基于患者偏好和需求的策略;以及（2）药物优化和取消处方（MOD）， 有针对性地优化抗抑郁药物的剂量，并停止有害或无效的药物。 目标1（适应）：通过协作规划方法，我们将适应、制定和实施 接受主要骨科手术的老年人的最佳围手术期心理健康干预包 程序.通过利益相关者的投入，我们将开发和迭代适应行为和药物 优化干预捆绑包，以便在该人群中实施。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迭代优化干预措施 来自65岁以上接受主要骨科干预的患者和其他利益相关者， 障碍和促进者来完成计划。目的2（试验）：使用混合1型随机对照 试验设计，我们将比较干预捆绑与常规护理在减轻症状方面的有效性 抑郁和焦虑在接受骨科手术的老年患者中的作用为此，100名患者 抑郁和焦虑的症状将被随机分配到药理学和行为学中 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， 术后结局，包括并发症、福尔斯、谵妄和疼痛。因此，药物优化， 对接受全关节置换术的老年人的抑郁和焦虑症进行停药和行为治疗 关节成形术可以改善抑郁和焦虑症状以及其他重要的术后 成果。

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.