Impact of physical activity on depression after cardiac surgery

Lower cardiac rehabilitation enrolment occurs in acute coronary syndrome patients who report low levels of physical activity at four weeks post-event: A prospective observational study using physical activity tracker data

BACKGROUND

Physical activity (PA) and cardiac rehabilitation (CR) attendance are important for recovery and prognosis following acute coronary syndrome (ACS). However, PA patterns early post-ACS are not well known.

OBJECTIVES

Investigate the level of PA at 4-weeks post-ACS and any potential associations with CR enrolment.

METHODS

We recruited patients admitted for ACS from cardiac wards and clinics at two hospital sites in Sydney, Australia. PA data were collected using wearable activity trackers worn at 4-weeks post-ACS, and CR enrolment was self-reported.

RESULTS

Participants (n = 61) were aged 66.7 ± 10.3 years, 74 % male, 61 % were married or partnered, and 33 % were diagnosed with ST-elevation myocardial infarction. Patients engaged in 7514±3355 steps per day and 44.6 ± 37.5 min of moderate-to-vigorous physical activity (MVPA). Patients who enrolled in CR exhibited higher daily step counts (p = 0.044), MVPA minutes (p = 0.001), and were more likely to meet PA guidelines. ACS patients who engaged in higher levels of MVPA were more likely to enrol in CR (odds ratio [OR] 1.46; 95 % confidence interval [CI] 1.08, 1.98). CR enrolment was also positively associated with being married or in an intimate partnership (OR 9.93; 95 % CI 1.83, 53.85) and absence of depressive symptoms (OR 11.86; 95 % CI 1.91, 73.74).

CONCLUSION

Lower CR enrolment rates were observed among less physically active patients at 4-weeks post-ACS. However, each 10 min increment in MVPA increased the odds of CR enrolment by 46 %. Future research should explore strategies to target this inactive and high-risk group, given the potential for a large prognostic gain with CR participation.

Predictors of Psychological Distress among Post-Operative Cardiac Patients: A Narrative Review

Following surgery, over 50% of cardiac surgery patients report anxiety, stress and/or depression, with at least 10% meeting clinical diagnoses, which can persist for more than a year. Psychological distress predicts post-surgery health outcomes for cardiac patients. Therefore, post-operative distress represents a critical recovery challenge affecting both physical and psychological health. Despite some research identifying key personal, social, and health service correlates of patient distress, a review or synthesis of this evidence remains unavailable. Understanding these factors can facilitate the identification of high-risk patients, develop tailored support resources and interventions to support optimum recovery. This narrative review synthesises evidence from 39 studies that investigate personal, social, and health service predictors of post-surgery psychological distress among cardiac patients. The following factors predicted lower post-operative distress: participation in pre-operative education, cardiac rehabilitation, having a partner, happier marriages, increased physical activity, and greater social interaction. Conversely, increased pain and functional impairment predicted greater distress. The role of age, and sex in predicting distress is inconclusive. Understanding several factors is limited by the inability to carry out experimental manipulations for ethical reasons (e.g., pain). Future research would profit from addressing key methodological limitations and exploring the role of self-efficacy, pre-operative distress, and pre-operative physical activity. It is recommended that cardiac patients be educated pre-surgery and attend cardiac rehabilitation to decrease distress.

Cardiac surgery improves the postoperative frailty score of frail patients

BACKGROUND

Cardiac surgery in frail patients has been reported to be associated with increased mortality and morbidity but may improve functional status of frail patients. Few studies have investigated the impact of cardiac surgery on the trajectory of postoperative frailty. We hypothesized that cardiac surgery in frail patients would improve frailty postoperatively.

METHOD

This study included 71 patients over 65 years old who were scheduled for cardiac surgery via sternotomy or thoracotomy. Frailty was prospectively evaluated using the Kihon Checklist (KCL) at 1 and 3 months postoperatively. Patients were divided into three groups based on the preoperative KCL score: nonfrail, prefrail, and frail. The interaction between the degree of preoperative frailty and the trajectory of postoperative KCL scores was assessed.

RESULTS

The KCL score changed significantly over time (P < 0.001), and the KCL score trajectory differed significantly according to the degree of preoperative frailty (P for interaction = 0.003). In the frail group, the KCL score was significantly lower 3 months postoperatively than preoperatively (median 8, interquartile range [5, 9] versus median 9, interquartile range (9, 13), P = 0.029).

CONCLUSION

The trajectory of postoperative KCL scores differed significantly depending on the degree of preoperative frailty. At 3 months after cardiac surgery, the KCL score of frail patients was significantly improved, while that in nonfrail patients was significantly deteriorated.

The effect of intravenous ketamine on depressive symptoms after surgery: A systematic review

STUDY OBJECTIVE

The development of depressive symptoms is an important complication experienced by patients postoperatively and is associated with poor clinical outcomes. Ketamine is a feasible treatment option for depressive symptoms after surgery due to its known antidepressant effect. This meta-analysis aimed to evaluate the current body of research regarding the effects of intravenous ketamine on depressive symptoms after surgery.

DESIGN

A meta-analysis of randomized controlled trials.

SETTING

Perioperative care area.

PATIENTS

Adult surgical patients.

MEASUREMENTS

Systematic literature search was performed in the CENTRAL, MEDLINE, and EMBASE databases, for randomized controlled trials comparing the effect of intravenous ketamine versus placebo on postoperative depressive symptoms as the primary outcome, with no language restrictions. Two independent reviewers screened records for inclusion, extracted data, and assessed risk of bias. Random effects models were used to pool overall estimates. Postoperative pain intensity was also examined. The GRADE approach was used to assess the quality of evidence.

MAIN RESULTS

Out of 834 records screened, 9 studies met our inclusion criteria, comprising a total of 2468 patients. Compared with the control group, ketamine provided significant reduction of postoperative depression scale scores, by a standardized mean difference (SMD) of -0.89 (95% CI [-1.23, -0.73], P = 0.33, I² = 13%; 4 studies) on postoperative day (POD) 1, SMD -0.51 (95% CI [-0.99, -0.04], P < 0.001, I² = 93%; 4 studies) on POD 3, suggesting clinically relevant reduction in postoperative depressive symptoms. Postoperative depression scale scores on POD 7 were also reduced in patients receiving ketamine compared to the control group, with SMD -0.33 (95% CI [-0.52, -0.14], P = 0.36, I² = 2%; 3 studies), but the minimal clinical difference of 0.5 SMD was not reached. No significant difference was observed in the postoperative depression scale over the long term at 30 days' follow-up (SMD -0.13, 95% CI [-0.25, 0.00], P = 0.07, I² = 52%; 5 studies). A significant reduction of postoperative pain intensity on POD 1 was identified in patients following ketamine administration (SMD -1.29, 95% CI [-2.57, -0.01], P = 0.05, I² = 98%; 5 studies). However, administration of ketamine resulted in a significantly increased risk of nausea and vomiting (RR 1.71, 95% CI [1.25, 2.33], P = 0.17, I² = 35%; 6 studies), headache (RR 4.88, 95% CI [1.97, 12.06], P = 0.83, I² = 0%; 4 studies), and hallucination (RR 34.94, 95% CI [8.59, 142.17], P = 0.44, I² = 0%; 4 studies).

CONCLUSIONS

The current evidence supports intravenous ketamine administration for the treatment of depressive symptoms after surgery. While ketamine administration has clinically significant side effects, future studies are needed in surgical populations at high risk of complications.

Clinical, Surgical, and Sociopsychological Factors and Depression After Cardiothoracic Surgery

BACKGROUND

Depression is highly prevalent in cardiac surgical patients and is associated with mortality. The objectives of the study were to evaluate depression scores longitudinally pre- and postoperatively and to examine the association between postoperative depression scores and clinical, surgical, and sociopsychological factors.

METHODS

Depression scores were assessed using the Center for Epidemiological Study of Depression (CES-D) in 100 cardiac surgical patients who underwent cardiac surgery preoperatively, during hospitalization, and at 2 and 6 week after discharge. Clinical, surgical, and sociopsychological predictors of depression scores were recorded.

RESULTS

The average depression scores significantly increased from preoperative levels (14.9 ± 1.07) to during hospitalization (21.5 ± 1.05) and decreased at both 2 weeks (15.8 ± 1.07) and 6 weeks after discharge (14.0 ± 1.06), as compared with scores during hospitalization (P < .001). The percentage of patients who scored CES-D > 16 increased significantly from preoperative (39%) to hospitalization (71%) and decreased gradually at 2 weeks (45%) and 6 weeks (37%) after discharge (P < .001). Significant predictors of high postoperative CES-D scores were female gender, ejection fraction < 50%, and high preoperative CES-D scores.

CONCLUSIONS

High depression scores after cardiac surgery suggest that perioperative screening and management of depression after surgery are necessary and may improve outcomes of these patients who are at high risk for depression. Further understanding of the factors that contribute to high depression scores is required to facilitate clinical intervention.

Responsiveness of the single item measure to detect change in physical activity

Objective

The objective of this study was to evaluate the responsiveness of the single item measure (SIM) to detect change in PA when compared to hip-worn accelerometry. A secondary aim was to provide further data on validity of the measure at a single time point.

Methods

Validity of the SIM to determine the number of days of ≥30 minutes of accelerometer-derived moderate-to-vigorous physical activity (MVPA) was assessed in 120 participants (78% female, 19% male, 3% other; age: 46 ± 11 years). Analysis of change was based on change in the number of days that participants completed ≥30 minutes of MVPA determined by the SIM and accelerometry over two 7-day periods in 90 participants (age: 47±11 years). Accelerometer data were analysed as total minutes of MVPA per day (MVPA-total) and as sustained bouts of 10 minutes or more of MVPA (MVPA-bouts). Validity of the SIM to detect change in MVPA, using accelerometer data as the reference measurement, was examined through Spearman’s correlation and agreement in classification of change between SIM and accelerometry. Responsiveness to change was assessed by standardised response means and Cohen’s d.

Results

Standardised response means for PA change were moderate for the SIM (0.77), MVPA-total (0.57) and MVPA-bouts (0.79). The correlation for change in number of days ≥30 minutes MVPA between the SIM and accelerometry were small to moderate (MVPA-total: r = 0.36 and MVP-bouts: r = 0.40). The SIM displayed moderate accuracy (60%-63%), using accelerometer data as the reference measurement, in detecting increases in days ≥30 minutes of MVPA.

Conclusion

The SIM is a potentially useful assessment tool for evaluating change in MVPA, particularly when device-based measures or longer self-report measures are not feasible.

The Manitoba Personalized Lifestyle Research (TMPLR) study protocol: a multicentre bidirectional observational cohort study with administrative health record linkage investigating the interactions between lifestyle and health in Manitoba, Canada

INTRODUCTION

Lifestyle factors, such as diet, physical activity and sleep, are associated with the development of many chronic diseases. The objective of The Manitoba Personalized Lifestyle Research study is to understand how these lifestyle factors interact with each other and with other factors, such as an individual's genetics and gut microbiome, to influence health.

METHODS

An observational study of adults, with extensive phenotyping by objective health and lifestyle assessments, and retrospective assessment of early life experiences, with retrospective and prospective utilisation of secondary data from administrative health records.

STUDY POPULATION

A planned non-random convenience sample of 840 Manitobans aged 30-46 recruited from the general population, stratified by sex (equal men and women), body mass index (BMI; 60% of participants with a BMI>25 kg/m²) and geography (25% from rural areas). These stratifications were selected based on Manitoba demographics.

MEASUREMENTS

Lifestyle factors assessed will include dietary pattern, physical activity, cardiovascular fitness, and sleep. Factors such as medical history, socioeconomic status, alcohol and tobacco consumption, cognition, stress, anxiety, and early life experiences will also be documented. A maternal survey will be performed. Body composition and bone density will be measured by dual energy X-ray absorptiometry. Blood pressure, pulse wave velocity, and augmentation index will be measured on two consecutive days. Chronic disease risk biomarkers will be measured in blood and urine samples. DNA will be extracted for genetic analysis. A faecal sample will be collected for microbiome analysis. Participants may provide their Manitoba personal health information number to link their study data with administrative health records.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the University of Manitoba Health Research Ethics Board (protocol # HS18951; 05/01/2016). Data analysis, release of results and publication of manuscripts are scheduled to start in early 2019. Additional information at www.TMPLR.ca.

TRIAL REGISTRATION NUMBER

NCT03674957; Pre-results.

Determinants of depression in patients with comorbid depression following cardiac rehabilitation

Background

A prior history of depression, at the point patients start cardiac rehabilitation (CR), is associated with poor outcomes; however, little is known about which factors play a part in determining the extent of benefit following CR. Therefore, we aim to identify and evaluate determinants of CR depression outcomes in patients with comorbid depression.

Methods

An observational study of routine practice using the British Heart Foundation National Audit of Cardiac Rehabilitation data between April 2012 and March 2017. Baseline characteristics were examined with independent samples t-test and χ² test. A binary logistic regression was used to predict change in depression outcome following CR.

Results

The analysis included 2715 CR participants with depression history. The determinants of Hospital Anxiety and Depression Scale (HADS) depression measurement post-CR were higher total number of comorbidities (OR 0.914, 95% CI 0.854 to 0.979), a higher HADS anxiety score (OR 0.883, 95% CI 0.851 to 0.917), physical inactivity (OR 0.707, 95% CI 0.514 to 0.971), not-smoking at baseline (OR 1.774, 95% CI 1.086 to 2.898) and male gender (OR 0.721, 95% CI 0.523 to 0.992).

Conclusion

Baseline characteristics of patients with comorbid depression such as higher anxiety, higher total number of comorbidities, smoking, physical inactivity and male gender were predictors of their depression levels following CR. CR programmes need to be aware of comorbid depression and these related patient characteristics associated with better CR outcomes.

Impact of preoperative physical activity and depressive symptoms on post-cardiac surgical outcomes

Objective

To determine the independent and combined impact of preoperative physical activity and depressive symptoms with hospital length of stay (HLOS), and postoperative re-hospitalization and mortality in cardiac surgery patients.

Methods

A cohort study including 405 elective and in-house urgent cardiac surgery patients were analyzed preoperatively. Physical activity was assessed with the International Physical Activity Questionnaire to categorize patients as active and inactive. The Patient Health Questionnaire-9 was used to evaluate preoperative depressive symptoms and categorize patients as depressed and not depressed. Patients were separated into four groups: 1) Not depressed/active (n = 209), 2) Depressed/active (n = 48), 3) Not depressed/inactive (n = 101), and 4) Depressed/inactive (n = 47). Administrative data captured re-hospitalization and mortality data, and were combined into a composite endpoint. Models adjusted for demographics, comorbidities, and cardiac surgery type. Multiple imputation was used to impute missing values.

Results

Preoperative physical activity behavior and depression were not associated with HLOS examined in isolation or when analyzed by the physical activity/depressive symptom groups. Physical inactivity (HR: 1.60, 95% CI 1.05 to 2.42; p = 0.03), but not depressive symptoms, was independently associated with the composite outcome. Freedom from the composite outcome were 76.1%, 87.5%, 68.0%, and 61.7% in the Not depressed/active, Depressed/active, Not depressed/inactive, and Depressed/inactive groups, respectively (P = 0.02). The Active/Depressed group had a lower risk of the composite outcome (HR: 0.35 95% CI 0.14 to 0.89; p = 0.03) compared to the other physical activity/depression groups.

Conclusion

Preoperative physical activity appears to be more important than depressive symptoms on short-term postoperative re-hospitalization and mortality.

Measuring change in trials of physical activity interventions: a comparison of self-report questionnaire and accelerometry within the PACE-UP trial

Background

Few trials have compared estimates of change in physical activity (PA) levels using self-reported and objective PA measures when evaluating trial outcomes. The PACE-UP trial offered the opportunity to assess this, using the self-administered International Physical Activity Questionnaire (IPAQ) and waist-worn accelerometry.

Methods

The PACE-UP trial (N = 1023) compared usual care (n = 338) with two pedometer-based walking interventions, by post (n = 339) or with nurse support (n = 346). Participants wore an accelerometer at baseline and 12 months and completed IPAQ for the same 7-day periods. Main outcomes were weekly minutes, all in ≥10 min bouts as per UK PA guidelines of: i) accelerometer moderate-to-vigorous PA (Acc-MVPA) ii) IPAQ moderate+vigorous PA (IPAQ-MVPA) and iii) IPAQ walking (IPAQ-Walk). For each outcome, 12 month values were regressed on baseline to estimate change.

Results

Analyses were restricted to 655 (64%) participants who provided data on all outcomes at baseline and 12 months. Both intervention groups significantly increased their accelerometry MVPA minutes/week compared with control: postal group 42 (95% CI 22, 61), nurse group 43 (95% CI 24, 63). IPAQ-Walk minutes/week also increased: postal 57 (95% CI 2, 112), nurse 43 (95% CI -11, 97) but IPAQ-MVPA minutes/week showed non-significant decreases: postal -11 (95% CI -65, 42), nurse -34 (95% CI -87, 19).

Conclusions

Our results demonstrate the necessity of using a questionnaire focussing on the activities being altered, as with IPAQ-Walk questions. Even then, the change in PA was estimated with far less precision than with accelerometry. Accelerometry is preferred to self-report measurement, minimising bias and improving precision when assessing effects of a walking intervention.

Trial registration: ISRCTN, ISRCTN98538934. Registered 2 March 2012.

Long-Term Health-Related Quality of Life in Living Liver Donors

BACKGROUND In living donor liver transplantation (LDLT), 2 patients undergo surgery, and the advantages and disadvantages for both patients should be considered. This study evaluated the long-term quality of life in living liver donors, and its impact on their activities of daily living focusing on mood and mental health. MATERIAL AND METHODS In total, 101 living liver donors (69 female and 32 male patients, median age of 36.8 years) were surveyed at a median time of 61.8 months after liver donation (range 7-169 months). The generic Short Form Health Survey (SF-36), the Patient Health Questionnaire 9 (PHQ-9), and the Questionnaire of Physical Activity (IPAQ) were used. The results of SF-36 were compared to a matched control group (n=72) using the Wilcoxon test; the SF-36, the PHQ-9, and the IPAQ scores were analyzed using Spearman's rank correlation. Linear regression model was used to check for dependencies between variables of interest. The IPAQ results were compared between the study group and the general Polish population. RESULTS There were no significant differences in the SF-36 domains between the study group and control group except body pain, which was higher in the living liver donor group (P<0.05). In 30.6% of patients, the PHQ-9 survey revealed mood disturbances. The PHQ-9 scores were higher in female-donors (P<0.05). Both summary scores of the SF-36 correlated to the PHQ-9 (P<0.001). In 89.1% of patients, physical activity was below the population norm and was lower in female donors than in male donors (P<0.01). CONCLUSIONS LDLT had no impact on donors' physical and mental health. Physical activity of living liver donors was lower than that of the general population. The SF-36 and the IPAQ measures seem to be reliable in the care of living liver donors. The PHQ-9 survey results and the inclination to depression of female living liver donors requires further study.

Factors associated with acute depressive symptoms in patients with comorbid depression attending cardiac rehabilitation

Background

The literature suggests that comorbid depression, defined in this paper as a history of depression prior to a cardiovascular event, has an impact on later onset depression as well as constituting increased risk of mortality and adverse cardiac events. However, which factors are associated with depression, specifically in patients with comorbid depression, is unclear. Therefore, this paper investigates the factors associated with depression in patients with comorbid depression attending cardiac rehabilitation (CR).

Methods

This observational study used routinely collected data from the British Heart Foundation National Audit of Cardiac Rehabilitation for the time period between April 2012 and March 2017. CR participants with comorbid depression were selected as the study population. An independent t-test and chi-square test were used to compare the association between acute depression symptoms and baseline characteristics in this population.

Results

A total of 2715 CR patients with comorbid depression were analysed. Characteristics associated with acute depressive symptoms in patients with comorbid depression were found to be: young age (MD: 2.71, 95% CI 1.91, 3.50), increased number of comorbidities (MD: -0.50, 95% CI -0.66, − 0.34), increased weight (MD: -1.94, 95% CI -3.35, − 0.52), high BMI (MD: -1.94, 95% CI -3.35, − 0.52), HADS anxiety (MD: -5.17, 95% CI -5.47, − 4.87), comorbid anxiety (52.4%, p <  0.001), physical inactivity (150 min moderate physical activity a week and 75 min vigorous exercise a week; 27.5%, p <  0.001; 5.6%, p <  0.001 respectively), smoking (12.7%, p <  0.001), and being less likely to be partnered (63.6%, p <  0.001).

Conclusion

The study demonstrated the association between a variety of clinical and socio-demographic factors and depression. The findings of the research indicated that, at CR baseline assessment, caution must be taken with patients with comorbid depression, specifically those with higher level depressive symptoms at the start of rehabilitation. Furthermore, their multi-comorbid condition must also be taken into account. Patients with higher depression symptoms and comorbid depression scored five points higher on the HADS anxiety scale in comparison to patients with lower level depression symptoms at the start of CR, which demonstrated that anxiety and depression are interrelated and present together.

Is Exercise Training Appropriate for Patients With Advanced Heart Failure Receiving Continuous Inotropic Infusion? A Review

Exercise-based rehabilitation programs have been reported to have beneficial effects for patients with heart failure. However, there is little evidence about whether this is the case in patients with more severe heart failure. In particular, there is a question in the clinical setting whether patients with advanced heart failure and continuous inotropic infusion should be prescribed exercise training. In contrast, many studies conclude that prolonged immobility associated with heart failure profoundly impairs physical function and promotes muscle wasting that could further hasten the course of heart failure. By contrast, exercise training has various effects not only in improving exercise capacity but also on vascular function, skeletal muscle, and autonomic balance. In this review, we summarize the effectiveness and discuss methods of exercise training in patients with advanced heart failure receiving continuous inotropic agents such as dobutamine.

Systematic review of preoperative physical activity and its impact on postcardiac surgical outcomes

OBJECTIVES

The objective of this systematic review was to study the impact of preoperative physical activity levels on adult cardiac surgical patients' postoperative: (1) major adverse cardiac and cerebrovascular events (MACCEs), (2) adverse events within 30 days, (3) hospital length of stay (HLOS), (4) intensive care unit length of stay (ICU LOS), (5) activities of daily living (ADLs), (6) quality of life, (7) cardiac rehabilitation attendance and (8) physical activity behaviour.

METHODS

A systematic search of MEDLINE, Embase, AgeLine and Cochrane library for cohort studies was conducted.

RESULTS

Eleven studies (n=5733 patients) met the inclusion criteria. Only self-reported physical activity tools were used. Few studies used multivariate analyses to compare active versus inactive patients prior to surgery. When comparing patients who were active versus inactive preoperatively, there were mixed findings for MACCE, 30 day adverse events, HLOS and ICU LOS. Of the studies that adjusted for confounding variables, five studies found a protective, independent association between physical activity and MACCE (n=1), 30-day postoperative events (n=2), HLOS (n=1) and ICU LOS (n=1), but two studies found no protective association for 30-day postoperative events (n=1) and postoperative ADLs (n=1). No studies investigated if activity status before surgery impacted quality of life or cardiac rehabilitation attendance postoperatively. Three studies found that active patients prior to surgery were more likely to be inactive postoperatively.

CONCLUSION

Due to the mixed findings, the literature does not presently support that self-reported preoperative physical activity behaviour is associated with postoperative cardiac surgical outcomes. Future studies should objectively measure physical activity, clearly define outcomes and adjust for clinically relevant variables.

REGISTRATION

Trial registration number NCT02219815. PROSPERO number CRD42015023606.

Psychological prognosis after newly diagnosed chronic conditions: socio-demographic and clinical correlates

BACKGROUND

This study was aimed toward discerning depressive symptom trajectories associated with different chronic conditions and toward finding modifiable factors associated with those trajectories.

METHODS

Data were drawn from the 1996-2007 Taiwan Longitudinal Study on Aging. Nine chronic conditions were selected, and mood trajectories were measured with the Center of Epidemiological Studies-Depression scale.

RESULTS

Among the nine chronic conditions we examined, four patterns of depressive symptom trajectories were identified: (1) elevated depressive symptoms and worsened over time after diagnosed with heart disease (n = 681), arthritis (n = 850), or hypertension (n = 1,207); (2) elevated depressive symptoms without worsening over time after diagnosed with stroke (n = 160), lung diseases (n = 432), gastric conditions (n = 691), or liver diseases (n = 234); (3) no elevated depressive symptoms after diagnosis but an increase in depressive symptoms over time for participants with diabetes (n = 499); and (4) no significant patterns after diagnosed with cancer (n = 57). Cumulative psychological burden over time was significant for participants with hypertension, diabetes, heart diseases, or arthritis. However, these effects disappeared after controlling for comorbidities and physical limitations. Moreover, psychiatric condition was found to play an important role in baseline depressive symptoms among participants diagnosed with lung diseases, arthritis, or liver diseases.

CONCLUSIONS

Findings from this study provide information in addressing psychological burden at different times for different conditions. In addition, minimizing the incidence of comorbidities, physical limitations, or psychiatric conditions may have the prospective effect of avoiding the trend of increased depressive symptoms, especially when adults diagnosed with hypertension, diabetes, heart diseases, arthritis, lung diseases, arthritis, or liver diseases.

Cardiac surgery as a stressor and the response of the vulnerable older adult

In an aging population, recovery and restoration of function are critical to maintaining independence. Over the past 50years, there have been dramatic improvements made in cardiac surgery processes and outcomes that allow for procedures to be performed on an increasingly older population with the goal of improving function. Although improved function is possible, major surgical procedures are associated with substantial stress, which can severely impact outcomes. Past literature has identified that frail patients, who are vulnerable to the stress of surgery, are more likely to have postoperative major adverse cardiac and cerebrovascular events (OR 4.9, 95% confidence interval 1.6, 14.6). The objective of this manuscript is to examine preoperative frailty in biological, psychological, and social domains using cardiac surgery to induce stress. We systematically searched PubMed for keywords including "cardiac surgery, frailty, and aged" in addition to the biological, psychological, and social keywords. In the biological domain, we examine the association of physiological and physical vulnerabilities, as well as, the impact of comorbidities and inflammation on negative surgical outcomes. In the psychological domain, the impact of cognitive impairment, depression, and anxiety as vulnerabilities were examined. In the social domain, social structure, coping, disparities, and addiction as vulnerabilities are described. Importantly, there is substantial overlap in the domains of vulnerability. While frailty research has largely focused on discrete physical vulnerability criteria, a broader definition of frailty demonstrates that vulnerabilities in biological, psychological, and social domains can limit recovery after the stress of cardiac surgery. Identification of vulnerability in these domains can allow better understanding of the risks of cardiac surgery and tailoring of interventions to improve outcomes.