Depression and anxiety after total joint replacement among older adults: a meta-analysis

OBJECTIVE

Patients usually experience good physical recovery after total joint replacement (TJR); however, it is unclear whether mood also improves. The current meta-analysis examined changes in depression and anxiety following TJR in older (≥50 years) patients in order to address this gap in the literature.

METHODS

Data from 26 studies (4045 TJR, 55 controls) that assessed depression and/or anxiety pre- and post-surgery in TJR patients, with or without a control group, were analyzed. Prevalence rates and Cohen's d effect sizes were used to evaluate changes in the prevalence and severity of depression/anxiety, respectively.

RESULTS

Approximately 23% of TJR patients had clinically significant levels of depression prior to surgery, which decreased to 13% one year later. The prevalence of anxiety could not be evaluated due to the limited available data. TJR patients did not show any clinically meaningful reductions in symptoms of depression or anxiety, following surgery. Compared to controls, there was no difference in symptom progression over time; although only one study examined this.

CONCLUSIONS

TJR patients appear to have higher rates of clinically significant symptoms of depression before and after surgery, compared to the general population, however more research with adequate control groups is needed to confirm this. Only a modest improvement in the severity of depression and anxiety symptoms was noted post-surgery. However, existing research is limited; preventing definite conclusions regarding the impact of TJR on mood.

Incidence of delirium following total joint replacement in older adults: a meta-analysis

OBJECTIVE

Delirium is common in older adults following total joint replacement (TJR) of the hip and knee. However, reports of the incidence of delirium vary widely, limiting their usefulness. The current meta-analysis therefore examined (1) the incidence of delirium in older patients who underwent TJR and (2) whether these rates vary according to the (a) joint (hip/knee replacement), (b) inclusion/exclusion of patients who underwent simultaneous bilateral surgery, (c) inclusion/exclusion of patients with preexisting cognitive impairments, (d) type of anesthesia (regional/general), (e) method/frequency of assessment, and (f) postoperative interval.

METHOD

Data from 24 studies (2,895 patients) that measured postsurgical delirium following TJR were analyzed. Mean weighted proportions were calculated using a random-effects model to assess the overall incidence of delirium and whether the rate varied according to the aforementioned variables.

RESULTS

Overall, 17% of patients who underwent TJR developed delirium during hospital admission. Individual estimates varied from 0% to 82%, but this variability was not adequately explained by the variables that were examined.

CONCLUSIONS

Delirium is relatively common following TJR; however, it remains unclear why individual estimates vary so widely. Health professionals working with these patients should remain alert to the presentation, diagnosis and management of delirium to optimize postsurgical outcomes.

Sustained response to deep brain stimulation in LRRK2 parkinsonism with the Y1699C mutation

Although effective deep brain stimulation of the subthalamic nucleus (STN-DBS) is reported in G2019S leucine-rich repeat kinase 2 (LRRK2) parkinsonism, response to surgery in other LRRK2 mutations has not been previously reported. We present an affected individual from the Lincolnshire pedigree (Y1699C), on whom bilateral STN-DBS was performed to control severe motor fluctuations and dyskinesias. He showed a marked improvement in Unified Parkinson's Disease Rating Scale (UPDRS) Part III scores in the "on" and "off" states, sustained for more than three years. Bilateral STN-DBS in LRRK2-parkinsonism with the Y1699C mutation can be as effective as in sporadic PD.

A syndromal analysis of neuropsychological outcome following coronary artery bypass graft surgery

BACKGROUND

Studies of neuropsychological outcome following coronary artery bypass graft surgery (CABG) have traditionally dichotomised patients as "impaired" or "unimpaired". This conceals the potential heterogeneity of deficits due to different mechanisms and sites of brain injury.

OBJECTIVES

To explore neuropsychological outcome following CABG and determine to what extent it conforms to prototypic cortical and/or subcortical neurobehavioral syndromes and whether different intraoperative physiologic measures are associated with different subtypes of neuropsychological outcome.

METHODS

Neuropsychological tests were administered to 85 patients before and after elective CABG and to 50 matched normal control subjects. Pre- to postoperative change scores were computed using standardised regression based norms. Change scores on selected memory measures were subjected to cluster analysis to identify qualitatively distinct subtypes of memory outcome. Emergent clusters were compared on non-memory measures, intraoperative physiologic measures, and demographic variables.

RESULTS

Three subtypes of memory outcome were identified: memory spared (48% of patients), retrieval deficit (35%), and encoding/storage deficit (17%). Contrary to expectation, the subgroups were indistinguishable on measures of confrontation naming and manual dexterity and on intraoperative cardiac surgical physiologic measures and demographic variables. The encoding/storage deficit subgroup exhibited executive dysfunction.

CONCLUSIONS

Heterogeneous profiles of neuropsychological dysfunction were found following CABG although they did not tightly conform to prototypic cortical and subcortical neurobehavioral syndromes. This challenges the value and appropriateness of the common practice of collapsing individual test scores to arrive at a single figure to define "impairment". Whether different subtypes of neuropsychological outcome are caused by different pathophysiologic mechanisms remains unknown.

A comparison of neuropsychologic deficits after extracardiac and intracaradiac surgery

OBJECTIVE

To compare the incidence of neuropsychologic deficits 1 week and 6 months after coronary artery bypass graft (CABG) surgery (extracardiac) and valve surgery with or without CABG surgery (intracardiac) using reliable change indices to define the incidence of neuropsychologic deficits.

DESIGN

Prospective study.

SETTING

Cardiac surgical unit in a university teaching hospital.

PARTICIPANTS

Patients scheduled for elective multiple-graft (> or =3 grafts) CABG surgery (n = 59), or elective valve surgery (with or without concomitant CABG surgery) (n = 50) and a matched sample of nonsurgical controls (n = 53).

INTERVENTIONS

Neuropsychologic assessments were performed 1 day before surgery, 7 days and 6 months after surgery.

MEASUREMENTS AND MAIN RESULTS

The 7-day assessment showed no significant differences between valve surgery patients and CABG surgery patients in the incidence of neuropsychologic deficits. When reassessed 6 months postoperatively, the valve group displayed a significantly higher incidence of deficits on the digit symbol test compared with the CABG group (valve 26.7% v CABG 6.8%). In the CABG group, there was a significant change in the incidence of deficits per patient from 7 days to 6 months (p = 0.03) that was not evident in the valve group.

CONCLUSION

There are some differences in the neuropsychologic outcome of extracardiac and intracardiac surgery. Patients undergoing isolated CABG surgery showed a greater reduction in the incidence of persisting deficits at 6 months than patients undergoing valve surgery with or without CABG surgery. This finding warrants further investigation, with particular attention to patients undergoing combined valve and coronary artery procedures.

Mood state as a predictor of neuropsychological deficits following cardiac surgery

OBJECTIVES

mood disorders and neuropsychological deficits are both commonly reported occurrences after cardiac surgery. We examined the relationship between mood state and postoperative cognitive deficits in this population.

METHODS

assessments of neuropsychological functions and mood state (depression, anxiety, stress scales; DASS) were performed preoperatively and postoperatively on 147 patients undergoing cardiac surgery.

RESULTS

the incidence of preoperative depression, anxiety, and stress symptomatology was 16%, 27%, and 16%, respectively. The incidence of postoperative anxiety symptomatology significantly increased to 45% (p<0.001), while the incidence of depression and stress symptomatology remained stable (19% and 15%, respectively; ns). Changes in mood state did not influence changes in neuropsychological performance. Preoperative mood was a strong predictor of postoperative mood, and was related to postoperative deficits on measures of attention and memory.

CONCLUSIONS

an assessment of preoperative mood is critical in identifying patients at risk of postoperative mood disorders and neuropsychological deficits. Measures assessing somatic manifestations of anxiety may not be suitable for a surgical population.

Neuropsychological dysfunction after minimally invasive direct coronary artery bypass grafting

BACKGROUND

We compared postoperative neuropsychological dysfunction after minimally invasive direct coronary artery bypass grafting (MIDCAB) operation with coronary artery bypass graft operations using cardiopulmonary bypass.

METHODS

Neuropsychological assessment was performed preoperatively and before discharge on 7 patients undergoing MIDCAB procedures, 9 patients undergoing single-graft cardiopulmonary bypass operation, and 27 patients undergoing multiple-graft cardiopulmonary bypass operation. From a matched control group of 40 normal subjects reliable change indices were derived for each measure and used to determine the incidence of postoperative decline.

RESULTS

There was little difference between the MIDCAB and single-graft cardiopulmonary bypass groups on the incidence of neuropsychologic decline. However, the multiple-graft cardiopulmonary bypass group had a significantly higher incidence of decline than the MIDCAB and single-graft cardiopulmonary bypass groups on specific neuropsychologic measures, coupled with a significantly greater number of postoperative deteriorations per patient.

CONCLUSIONS

The elimination of cardiopulmonary bypass does not prevent neuropsychological dysfunction after cardiac operation as patients undergoing MIDCAB and single-graft cardiopulmonary bypass experience similar deteriorations in performance. However, the deterioration is markedly worsened when the number of surgical grafts is increased.

Neuropsychologic changes after coronary artery bypass grafting: use of reliable change indices

BACKGROUND

A method of defining change in neuropsychologic test scores that accounts for test reliability and practice effects was applied to determine accurately the incidence of acquired neuropsychologic deficits after coronary artery bypass grafting.

METHODS

Neuropsychologic assessment was performed on 50 patients before and at 7 days after either hypothermic or normothermic coronary artery bypass grafting. From a matched control group of 24 normal subjects who were examined twice over a similar interval, reliable change indices that controlled for measurement error and practice effects were calculated for each neuropsychologic measure. With the use of these indices, the incidence of postoperative decline among the study patients was determined. For comparison, the incidence of decline using the "one standard deviation" criterion also was calculated.

RESULTS

Comparing the reliable change and standard deviation methods, statistically significant differences in the incidence of decline were observed in 5 of 11 neuropsychologic measures. The reliable change method identified more patients with neuropsychologic deficits on most measures.

CONCLUSIONS

The control of measurement error and practice effects can alter significantly the calculated incidence of neuropsychologic impairment after coronary artery bypass grafting.

Individual patient prediction of seizure lateralization in temporal lobe epilepsy: a comparison between neuropsychological memory measures and the Intracarotid Amobarbital Procedure

Neuropsychological assessment has been extensively used in the presurgical evaluation of temporal lobe epilepsy (TLE) patients to assist in determining lateralization of seizure onset. Very few studies have examined the accuracy with which commonly used neuropsychological instruments provide this information in the individual patient. In 81 patients (49 right-, 32 left-TLE) without space-occupying lesions in whom correct seizure lateralization was inferred on the basis of postsurgical seizure-free status, we compared the frequency with which discrepancies between the Wechsler Memory Scale-Revised (WMS-R; Wechsler, 1987) Verbal and Visual Memory Indices, Warrington Recognition Memory Test (WRMT; Warrington, 1984) Words and Faces scaled scores, and Intracarotid Amobarbital Procedure (IAP) hemispheric memory scores correctly predicted seizure lateralization in the individual patient. Using both clinical analysis and discriminant function analyses (DFA), the IAP was found to be a clearly superior predictor of seizure laterality to the neuropsychological measures, whether used individually or in combination with one another. Using clinical analysis the WRMT was found to be a superior predictor to the WMS-R, which frequently gave false lateralizing information. Using all 3 measures in combination with one another, 87.1% of patients were correctly lateralized using DFA. Correctly lateralized patients were older and had longer durations of seizure disorder.

Intracarotid amobarbital procedure as a predictor of material-specific memory change after anterior temporal lobectomy

Memory testing during the intracarotid amobarbital procedure (IAP) is used extensively to identify temporal lobe surgery candidates "at risk" for developing severe postoperative anterograde amnesia. However, the utility of the IAP in predicting commonly observed material-specific memory deficits has not been thoroughly investigated. We examined the utility of contralateral IAP memory testing, as an index of the functional capacity of the surgical temporal lobe, to predict postoperative material-specific memory changes on the Wechsler Memory Scale-Revised (WMS-R) in patients with left hemisphere speech dominance undergoing left (n = 32) and right (n = 31) temporal lobectomy (TL). Left TL patients who "passed" contralateral IAP memory testing (> or = 68% recognition of memory items) had significantly greater verbal memory decrements than those who "failed" the IAP, presumably as a result of removal of functional tissue. A similar relationship between contralateral IAP performance and visual memory performance was not observed among right TL patients. Thus, the functional adequacy of the tissue to be resected appears to be inversely related to postoperative verbal memory decrement, at least among left TL patients. This relationship is consistent with results of recent studies demonstrating an inverse relationship between verbal memory decrements after left TL and preoperative neuropsychological verbal memory performance, magnetic resonance imaging (MRI) hippocampal volumes, and degree of mesiotemporal sclerosis (MTS).