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

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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.