INTRODUCTION
Many older individuals suffer from chronic knee joint pain due to osteoarthritis, a degenerative joint disease. Knee joint pain often limits mobility, making it difficult to walk, climb stairs, or perform daily activities. Total knee arthroplasty (TKA), also known as total knee replacement, is a surgical procedure designed to replace a damaged knee joint with artificial implants. TKA can significantly reduce or eliminate this pain. TKA can restore lost mobility, allowing individuals to regain independence. By reducing pain and improving mobility, TKA can significantly enhance an older person’s overall quality of life, enabling them to participate in social activities and enjoy a more active lifestyle.
However, older people may require a more tailored and prolonged rehabilitation program after TKA. Motivation and cognitive function are essential for rehabilitation. Depression or cognitive decline can affect the therapeutic outcome of TKA in older people. A recent study that analyzed the functional prognosis of 100 older people who underwent TKA identified substantial disparities in cognitive impairment among individuals diagnosed with depression[1]. In this paper, we explore the extent to which cognitive function and depression in older individuals undergoing TKA should be given consideration.
THE NEED FOR TKA IN OLDER PEOPLE
The global population is aging, leading to a higher prevalence of osteoarthritis, the primary condition requiring TKA. Advances in surgical techniques and implant technology have made TKA safer and more effective, expanding its applicability to older patients. Greater awareness of TKA as a treatment option and improved access to orthopedic care have contributed to its increased utilization. There’s a clear trend of TKA being performed on increasingly older patients[2]. While age was once a greater limiting factor, modern techniques and better patient management have changed this. In general, TKA has demonstrated very positive outcomes in older people, with significant pain relief and improved function. Even very older individuals, including those in their nineties, can experience substantial benefits from TKA[2].
However, older people have a higher risk of postoperative complications, including: Increased risk of infection, increased risk of cardiovascular complications, increased risk of falls, and increased risk of readmission[3]. Therefore, preoperative assessment and optimization of comorbidities are crucial to minimize these risks. Factors that can affect prognosis include patient’s overall health and comorbidities, bone quality, adherence to rehabilitation, and the presence of cognitive impairment[4]. TKA is a viable and often very successful option for older people with severe knee osteoarthritis. While risks are higher in this population, careful patient selection, preoperative optimization, and tailored rehabilitation can lead to significant improvements in pain and function. The impact of physical function and bone condition on surgical indications has been examined, but little research has been done on risk assessment of mental function. In the study by Nicolino et al[1], the occurrence of depression was associated with decline in cognitive function and frailty, but it had little effect on surgical outcomes and did not narrow the indications for TKA, which is good news for older people.
THE NEED FOR COGNITIVE ASSESSMENT
Cognitive assessment plays a crucial role in the preoperative evaluation of older people undergoing TKA. Cognitive impairment in patients undergoing TKA is associated with an increased risk of postoperative delirium (POD)[5], worsened postoperative functional status, and discharge to non-home facility[6]. POD was most common in older patients with baseline cognitive impairment. Individuals with POD had higher rates of 90-day postoperative surgical and joint-related complications. POD can lead to increased hospital stay, complications, and poorer functional outcomes.
Cognitive function influences a patient’s ability to understand and follow postoperative rehabilitation protocols. Impaired cognition can hinder their participation in physical therapy, affecting their recovery. Cognitive assessment helps determine a patient’s capacity to understand the risks and benefits of TKA and provide informed consent. This ensures that patients are making autonomous decisions about their care. Identifying cognitive impairment allows healthcare providers to tailor postoperative care to the patient’s needs. This may involve simplified instructions, increased support, and closer monitoring. Cognitive status can influence functional outcomes and patient satisfaction after TKA. Preoperative assessment can help identify patients at risk for poorer outcomes and guide interventions. Older people are at higher risk of having some form of cognitive decline. The assessment of cognitive function in older people scheduled for preoperative TKA requires a multifaceted approach combining standardized tests such as the mini-mental state examination, Montreal Cognitive Assessment, and clock drawing with the patient’s medical history[7]. Cognitive assessment in individuals undergoing TKA has been demonstrated to optimize patient safety, improve postoperative outcomes, and ensure that patients receive appropriate care throughout the surgical process.
THE NEED FOR DEPRESSION ASSESSMENT
The relationship between depression and TKA outcomes in older adults is complex and has garnered increasing attention in recent years. Associations between preoperative depression and TKA outcomes include increased pain perception, impaired functional recovery, and increased risk of complications. Depression can heighten pain sensitivity, leading to patients reporting more intense postoperative pain[8]. This can negatively impact their perception of recovery and satisfaction with the procedure. Depression can reduce motivation and adherence to rehabilitation programs, resulting in poorer functional outcomes[9]. Patients may have difficulty engaging in physical therapy and regaining mobility. Some studies suggest that preoperative depression may increase the risk of postoperative complications, such as infections and delayed wound healing[10]. This can be due to the negative mindset that is related to depression. Depression inherently reduces quality of life, and when combined with the stress of surgery and recovery, can severely impact the patients’ overall well-being. Moreover, postoperative depression can further hinder rehabilitation efforts and slow down recovery[11]. It can exacerbate pain and disability, leading to a cycle of negative reinforcement. Postoperative depression can decrease a patients will to participate in their rehabilitation[11].
Routine screening for depression in older adults undergoing TKA is essential. Tools like the Patient Health Questionnaire-9 and the Geriatric Depression Scale can be used[12]. A multidisciplinary approach, in which orthopedic surgeons, geriatricians, and mental health professionals share these indicators, is imperative. This approach allows for comprehensive assessment and management of both physical and mental health. Addressing depression through preoperative and postoperative interventions, such as therapy and medication, may improve TKA outcomes. Optimizing mental health can enhance patient motivation, adherence to rehabilitation, and overall satisfaction[13]. Social isolation, and lack of social support can greatly increase the risk of depression, which then negatively effects TKA outcomes. Depression can significantly impact TKA outcomes in older adults, affecting pain perception, functional recovery, and overall satisfaction[14]. Therefore, it is crucial to address depression as part of the comprehensive care of these patients.
DEPRESSION IS COMMON IN INDIVIDUALS WITH OSTEOARTHRITIS
Depression is indeed common in individuals with osteoarthritis. Research has consistently shown a significant association between these two conditions[15]. Osteoarthritis causes chronic pain, which can significantly impact a person’s daily life, limiting their mobility and independence. This chronic pain and disability can lead to feelings of frustration, helplessness, and hopelessness, contributing to depression. The limitations imposed by osteoarthritis can affect a person’s ability to participate in social activities, hobbies, and work. This reduction in quality of life can negatively impact mental well-being and increase the risk of depression. Some research suggests that the inflammatory processes involved in osteoarthritis may also play a role in the development of depression[16]. There are research papers that show that inflammatory cytokines are involved in both osteoarthritis and depression[17]. Pain from osteoarthritis can disrupt sleep patterns, leading to insomnia and poor sleep quality[18]. Sleep disturbances are a known risk factor for depression. The psychological impact of living with a chronic condition like osteoarthritis can also contribute to depression. This includes things like dealing with the change of body image, and the feeling of loss of control. Therefore, it’s crucial for healthcare professionals to assess and address both the physical and mental health needs of patients with osteoarthritis.
LIMITATIONS OF THE RESEARCH METHODOLOGY
There is a consensus that both physical and mental considerations are necessary for patients undergoing TKA. However, further research is necessary to determine the extent to which each factor has an impact. In the study by Nicolino et al[1], depression did not have a significant impact on the outcome of surgery. However, the study was conducted retrospectively, and the subjects were patients who underwent TKA, which introduces the possibility of selection bias. To address this gap in knowledge, it is recommended that future studies augment the number of cases and employ multivariate analysis, incorporating variables such as age, sex, preoperative nutritional status, bone condition, activity level, pain severity, cognitive function, and depression severity. This approach would facilitate a comprehensive examination of whether mental function serves as an explanatory factor for the outcomes of surgical procedures. Statistical techniques, such as regression analysis, are employed to ascertain the independent effect of psychological factors on TKA outcomes, while controlling for other potential confounding variables (e.g., age, severity of osteoarthritis, comorbidities)[19]. Correlation analysis can be used to examine the relationships between specific psychological factors and TKA outcomes[20]. Alternatively, a prospective study is necessary to examine how depression affects the outcome of surgery, with cases divided according to the severity of depression under strict physical surgical indications. In addition, intervention trials are required to ascertain whether interventions for depression have a positive effect on the outcome of surgery. Researchers can conduct interventional studies to evaluate the effectiveness of psychological interventions (e.g., cognitive-behavioral therapy, mindfulness-based interventions) in improving TKA outcomes[21].
CONCLUSION
The relationship between physical pain and mental well-being is a complex and multifaceted one. Pain has been demonstrated to exacerbate depression, and depression has been shown to worsen pain perception. A failure to address either aspect may impede the successful management of the other. Addressing both physical and mental health can lead to enhanced pain management, improved function, and an elevated quality of life for older individuals afflicted with osteoarthritis. A holistic approach, which acknowledges the patient as a whole person rather than merely a set of symptoms, is essential for effective treatment. This holistic approach fosters a sense of empowerment, leading to enhanced overall well-being. Conducting comprehensive assessments that encompass pain levels, functional limitations, and psychological well-being (e.g., screening for depression and anxiety) is paramount. Involving a multidisciplinary team, comprising physicians, physical therapists, occupational therapists, psychologists, and social workers, is also paramount. The implementation of effective pain management strategies, including surgical interventions such as TKA, the administration of medication, physical therapy, and other non-pharmacological approaches, is paramount. Furthermore, it is essential to facilitate access to mental health services, such as counseling or therapy, to address depression, anxiety, and other psychological concerns. Furthermore, patients should be educated about osteoarthritis, pain management techniques, and coping strategies for dealing with the emotional challenges of the condition. The establishment of open communication and the demonstration of empathy are crucial in fostering trust and rapport with patients. Patients’ concerns, both physical and mental, must be actively listened to. Regular follow-up appointments are crucial for monitoring the patient’s physical and mental health progress and adjusting treatment plans as necessary.
Provenance and peer review: Invited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Medical laboratory technology
Country of origin: Japan
Peer-review report’s classification
Scientific Quality: Grade B
Novelty: Grade B
Creativity or Innovation: Grade B
Scientific Significance: Grade B
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P-Reviewer: Sanusi KO S-Editor: Wu Y L-Editor: A P-Editor: Lei YY
