Perioperative mental health intervention for older adults undergoing cardiac surgery

摘要/项目摘要-项目3 抑郁症和焦虑症在接受心脏手术的老年人中很常见，但没有得到充分治疗。 在美国，每年约有40万老年人接受心脏手术， 这些人中有四分之一有术前焦虑或抑郁的症状。这其中的每一个 与一般老年人口相比，个人患抑郁症/焦虑的风险更大。围手术期 这段时期是一个特别脆弱的时期，因为病人同时面临着社会、功能和 伴随大手术而来的身体变化。大多数患有心脏病和抑郁症的老年人或 焦虑症没有接受适当的心理健康治疗，如果接受了治疗，通常仅限于 药物干预，进一步加剧了本已猖獗的多药联用。在这项提案中，我们将 优化和测试老年心脏手术患者的药物和行为干预捆绑包 手术，临床上有明显的抑郁和焦虑症状。我们将建立围手术期的心理状态 医疗保健干预捆绑包包括：(1)应用经过验证的行为干预、行为激活 (BA)，根据患者的喜好和需要制定战略；以及(2)药物优化和 停药(MOD)，目标是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)：在协作规划办法的指导下，我们将适应， 为老年人制定和实施最佳围手术期心理健康干预捆绑包 主要的侵入性心脏手术。通过利益相关者的投入，我们将开发并迭代地调整 在这一人群中实施的行为和药物优化干预捆绑。跟随 最初的方案开发，通过治疗开发试验，我们将反复优化干预 通过接受主要心脏干预的65岁以上患者的互动反馈，以及其他 利益相关者，注意到完成计划的障碍和促进者。目标2(测试)：使用混合类型1 随机对照试验设计，我们将比较干预捆绑和常规护理的有效性 在减少老年心脏手术患者的抑郁和焦虑症状方面。为了达到这个目的， 100名有抑郁和焦虑症状的患者将被随机分配到药物和 行为干预捆绑或常规护理。术前抑郁和焦虑与宿主有关 手术后的不良后果，包括医疗并发症、跌倒、精神错乱和死亡率。因此， 药物优化和停药，与行为激活治疗捆绑在一起的干预 接受心脏手术的老年人的抑郁和焦虑，预计不仅会改善症状 不仅是抑郁和焦虑，而且还有其他重要的术后结果。

Abstract/Project Summary – PROJECT 3 Depression and anxiety are common but undertreated in older adults undergoing cardiac surgical procedures. Approximately 400,000 older adults undergo cardiac surgery annually in the United States, and between a quarter and a half of these individuals have symptoms of preoperative anxiety or depression. Each of these individuals are at greater risk for depression/anxiety than the general older population. The perioperative period is a particularly vulnerable time, as the patient is concurrently confronted with social, functional and physical changes that accompany a major surgery. Most older adults with heart disease and depression or anxiety do not receive appropriate mental health treatment, and if they do, it is typically limited to pharmacologic interventions, further exacerbating already rampant polypharmacy. In this proposal, we will optimize and test a pharmacological and behavioral intervention bundle for older patients undergoing cardiac surgery, with clinically significant depressive and anxiety symptoms. We will institute a perioperative mental healthcare intervention 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 invasive cardiac 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 cardiac 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 cardiac 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 medical complications, falls, delirium, and mortality. Thus, medication optimization and deprescribing, in an intervention bundle with behavioral activation treatment of depression and anxiety in older adults undergoing cardiac surgery, is expected to improve not only symptoms of depression and anxiety but also other important post-operative outcomes.