Prevalence of depression and anxiety and associated factors among geriatric orthopedic trauma inpatients:A cross-sectional study

INTRODUCTION

Throughout the lifespan, orthopedic trauma patients are often accompanied by anxiety and depression. In previous studies, the incidence of anxiety was 4.8%-39.8%[1-3] and the incidence of depression was 22.3%-87.6%[1,2,4,5]. From the perspective of age stratification, anxiety and depression are common in elderly people. The incidence of generalized anxiety disorder was reportedat 0.7%-12%[6-9] and depression was 9%-11%[7,8]. In addition, anxiety and depression can occur separately or often together in elderly people[8]. However, until the last decade, common mental disorders such as anxiety and depression in geriatric orthopedic trauma patients received little attention in research, not to mention the huge burden of mental illness on families, society and the economy[6]. Therefore, it is urgent to understand, develop and evaluate evidencebased treatments for anxiety and depression among this specific group of patients.Before treatment, it is a top priority to establish the psychological characteristics and related factors of geriatric orthopedic trauma patients.

There are currently many scales assessing anxiety and depression among various target groups, such as the 15-item Geriatric Depression Scale[8], State-Trait Anxiety Inventory[10], Hospital Anxiety and Depression Scale[11], EuroQol (Quality of life)-5 Dimensions[12] and 7-item Generalized Anxiety Disorder Scale[8]. However, due to the time-consuming and professional evaluation, they have not been widely used in clinical practice. Therefore, based on the large size and unique cultural characteristics of Chinese people, Wang[13] designed a new screening scale [Huaxi Emotional-Distress Index, (HEI)] for identifying emotional disorders such as anxiety, depression and suicidal tendency.

Chen JL performed study design, data collection and manuscript drafting and revision; Luo R performed data analysis and interpretation;Liu M performed language editing and data collection; all authors have read and approved the manuscript.

MATERIALS AND METHODS

Study design

This cross-sectional study was performed in geriatric patients with orthopedic trauma admitted to West China Hospital between May 2015 and December 2017. Inclusion criteria were as follows: (1) Aged ≥ 60 years, both sexes; and (2) Musculoskeletal injury(including closed or open fracture, joint isolation, muscle/vessel/nerve soft tissue injury). Exclusion criteria were: (1) Cognitive impairment or consciousness disorder;(2) Refusal to participate; (3) Incomplete questionnaire; (4) Unable to communicate; (5)Central nervous system disorder due to acute trauma; and (6) Significant symptoms or a history of mental illness. The demographic, social and clinical data including age,sex, marital status, education level, Injury Severity Score (ISS), Visual Analog Score(VAS), injury type, surgery type and number of chronic diseases were collected from the Hospital Information System of West China Hospital.

A few studies have found no association between education level and emotional disorders[24,32]. However, the present study revealed that the education level among geriatric orthopedic patients was significantly positively associated with HEI score > 8.Those with a junior college education or above had a lower risk of developing anxiety and depression than those who were illiterate. In China, receiving better education and skill training increases job opportunities, and work brings better economic and social support so that people have more strength and resources to counteract frustrations and difficulties. This may explain why a higher educational level was a protective factor for emotional disorders. Lack of socioeconomic support and unemployment are risk factors for depression and anxiety[3,5,26].

Assessment of variables

Age, sex, marital status, education level, and HEI were assessed using the standard version of questionnaires. Pain was measured with a VAS ranging from 0 (no pain) to 10 (worst pain). The VAS and HEI were calculated by trained nurses after patients filling in the results according to their actual situation. The ISS was used to measure the severity of the injury during the time of enrollment. Injury type, surgery type, and number of chronic diseases were determined by surgeons’ reports and patients’reports of medical history–diagnosed hypertension, diabetes, cardiovascular disease,chronic lung disease, cerebrovascular disease, hepatic dysfunction, and renal dysfunction. For patients with an emotional disorder, psychological or psychiatric consultations were conducted for specialized treatment. The detailed process and response strategies are shown in Figure 1.

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Statistical analysis

Continuous variables are expressed as mean ± SD, and categorical variables are expressed as absolute values and percentages. Differences in continuous variables were tested using the-test, and differences in categorical variables were assessed using the Pearsontest. Binary logistic regression analyses were used to evaluate anxiety and depression, adjusted for age (continuous), sex (categorical), marital status(categorical), education level (categorical), ISS (continuous), VAS (continuous), injury type (categorical), surgery type (categorical), and number of chronic diseases(categorical). Odds ratios and 95% confidence intervals were calculated. All statistical analyses were carried out using SPSS version 21.0 (IBM, Chicago, IL, United States). Avalue < 0.05 was regarded as statistically significant. The statistical methods of this study were reviewed by a member of the Clinical Study Design and Statistics Service from the West China Hospital, Sichuan University.

RESULTS

Patients’ characteristics

Among the 966 patients, 487 were male and 479 were female, with a mean age of 70.2 ±7.1 years. The age ranged from 60 to 90 years. Of this sample, 89.2% of patients were married. Nearly two-thirds of the patients were admitted to the hospital with fractures. The average ISS was 4.47 ± 3.65. Illiteracy (12.9%) and semi-illiteracy (33.6%)accounted for almost half of the total number of patients. The vast majority (87.3%) of patients required elective surgery. Almost two-thirds of elderly patients suffered from chronic diseases. The basic demographic, clinical and social characteristics of the enrolled patients are shown in Table 1.

Prevalence of anxiety and depression and related factors

Among the 966 elderly patients, 75 had an HEI score > 8, suggesting that about 7.8% of patients with orthopedic trauma had emotional disorders (Table 1). A higher ISS (4.17± 3.107.96 ± 6.68,< 0.001), higher VAS (5.05 ± 1.096.89 ± 1.23,< 0.001),number of chronic diseases (< 0.001), injury type (= 0.038), and education level (=0.001) were significantly associated with HEI score > 8 (Table 2). Binary logistic regression analysis indicated that a higher ISS (= 0.024), higher VAS (< 0.001), two or more chronic diseases (< 0.001), and junior college education or above (= 0.047)were independently associated with anxiety and depression (Table 3).

DISCUSSION

More than 70% of adults have experienced different traumatic events in their lifetime,and trauma such as traffic accidents, falling from height, and power tool injuries are common in China[14,15]. In addition, the global population is growing older.According to a UN report, as of 2020, the total population > 60 years old exceeded 1 million and by 2050, the number will peak at 1.6 million[16]. Therefore, the number of elderly orthopedic trauma patients has also increased annually as the population has shifted to older age.

Orthopedic trauma research in the past has been substantially focused on implant development and technique improvement involved in the treatment of these injuries[17]. The biopsychosocial model proposed by George Engel[18] in 1977 has not been fully applied in orthopedic trauma practice and research. Orthopedic trauma is often accompanied by various psychiatric symptoms, such as negative emotions, intrusion,and avoidance symptoms. According to the Diagnostic and Statistical Manual of Mental Disorders, 5edition (DSM-V), the psychiatric symptoms could manifest as acute stress disorder (ASD), post-traumatic stress disorder, depression, or anxiety[19].Several studies have assessed the influence of the superimposed factors of old age and trauma on patients’ emotions. A study found that a few social and biological factors were related to the occurrence of ASD in elderly patients with osteoporotic fractures[20]. Unfortunately, orthopedic surgeons have paid insufficient attention to this.

The present study offers an introduction to the understanding of anxiety and depression and their associated factors affecting the recovery and healing among geriatric patients with orthopedic trauma in China. In the present study, the prevalence of emotional disorders was 7.8%. Our result was lower than 12.4% in Australia among hospitalized orthopedic trauma patients using Generalized Anxiety Disorder Scale Two item instrument[21], and 31.2% in the United States among orthopedic trauma patients using State-Trait Anxiety Inventory-S instrument[10], but higher than 6.25% in the UK among pelvic trauma patients using EuroQol (Quality of life)-5 Dimensions instrument[22]. This was most likely due to differences in sample size, timing and instruments used to measure these psychological parameters. In addition, most studies included adults of all ages and did not individually screen out elderly patients.

It needs to be emphasized that the ratio of male to female patients was almost equalin the present study, which was different from the high proportion of male patients in many previous studies[12,22,23].Although a few studies indicated that the prevalence of depression and anxiety in women was higher than in men, no similar result was found in the present study[3,5]. This indicates that, in the Chinese elderly population, the prevalence of emotional disorders is not significantly different between men and women.

Grade E (Poor): 0

Pain plays an important role in the quality of life. Many studies have found that pain is closely related to depression and anxiety[3,11,24,27]. Srahbzu[3] found that those who had pain within the last 24 h were 2.02 and 2.75 times more likely to develop depression and anxiety, respectively, than those without pain. In our study,those who had a higher VAS after orthopedic injury were 3.8 times more likely to develop anxiety and depression than those who had a lower VAS. In our experience,most elderly people have reduced tolerance to pain, so the severity and persistence of pain are more likely to lead to depression and anxiety. Most elderly people have sleep disorders. Pain can aggravate sleep disorders, which in turn exacerbate the pain. This vicious cycle is more likely to cause depression and anxiety.

Older adults with anxiety and depression frequently present with a variety of comorbid chronic illnesses[28,29]. In the present study, the number of chronic diseases was found to be associated with HEI > 8 on logistic regression. Those who had two or more chronic diseases had a higher risk of developing anxiety and depression when compared to those who did not have a chronic disease. A few studies indicated the presence of dysregulated homeostatic biological pathways in patients with depressed and anxiety, such as increased inflammation and disrupted energy-regulating neuroendocrine signaling (, leptin, insulin)[29-31]. However, the causal relationship between chronic diseases and emotional disorders seems to need clarification in the future. In addition, they are more like a pair of reciprocal relationships[28].

HEI was used to evaluate the severity of anxiety and depression. The Cronbach’s α of HEI was 0.90, and sensitivity and specificity were 0.880 and 0.766, respectively[13].There are nine self-reported items in total and all items are 5-point Likert-scaled with scale points 0-4. There are four grades based on the sum of the scores of nine items:normal (0-8 points), mild (9-12 points), moderate (13-16 points) and severe (17-36 points). The tenth and 11th item is not included in the total score (expanded to 11 items only in serious cases), but the results serve as a reference for medical staff.Details of HEI are presented in Supplementary material.

Depression involves an entire clinical spectrum from mild to severe[33]. Therefore,depression should be considered in the patients with HEI score < 8. Importance should be attached to the dynamic evaluation of emotions in elderly patients with orthopedic trauma as changes in disease progression or other serious stress events, such as loss of family members and appearance of malignant tumors, may occur during treatment.

This study had some limitations. First, it was a single-center study. Therefore, there must have been some selective bias. Second, this study did not investigate other possible risk factors, such as ethnicity, religion, insurance type, and substance abuse,that may have significantly affected the psychological condition of the patients. Third,this was a cross-sectional study, lacking longitudinal data, so it was difficult to confirm the causality. Hence, future studies need to be conducted to clarify these issues.

CONCLUSION

Emotional disorders, especially anxiety and depression, were common findings in geriatric patients who sustained orthopedic trauma. We would encourage clinicians to remain vigilant for emotional disorders and screen for emotional disorders in geriatric patients during the evaluation and treatment of other conditions. Psychological intervention or psychiatric treatment should be carried out.

This study aimed to analyze the data of geriatric orthopedic trauma patients from our hospital in order to investigate the prevalence of emotional disorders and identify demographic, social and clinical risk factors.

Orthopedics

对方案1、方案4按年费用最小法[7]计算结果如表7所示。年运行费用包括年电能损失费、运行维护费率1.4%、投资回收率10%。

This study was performed in elderly patients aged of 60 years or older with orthopedic trauma admitted to a level I trauma center between May 2015 and December 2017.Demographic, social, and clinical characteristics were described. Huaxi Emotional-Distress Index (HEI) was used to evaluate the severity of anxiety and depression status.

培养藏族小学生的阅读能力，对促进藏族小学生全面发展具有重要意义。阅读作为小学语文的重要组成部分，是学生语文学习的重点。所以在小学语文教学过程中，教师应注重对学生阅读能力培养，应根据小学生的实际情况以及语文教学内容，为学生创造科学、合理的教学情境，让学生在阅读中感受阅读的乐趣，使得藏族小学生掌握更多的阅读技巧，提高其自主阅读能力，加强藏族小学生的阅读效果，从而促进藏族小学生的不断发展。

Among the 966 patients, 75 patients had an HEI score > 8, accounting for about 7.8% of all patients. A higher Injury Severity Score, higher Visual Analog Score, number of chronic diseases, injury type, and education level were significantly associated with HEI score > 8. On logistic regression, a higher education level was a protective factor for emotional disorders, whereas Injury Severity Score, Visual Analog Score, two or more chronic diseases were the related independent risk factors.

口语交际是学生成长过程中最为基础的、最常用的交流方式，是学生展示自我、表述问题的必备技能。学生的口语交际、沟通能力，无论是对于当下的学习还是未来的成长，都具有重要的意义。因此，新课程改革背景下，教师在小学语文的教学中，应当抓住学生语言训练的关键期，从多角度、多方面入手，培养学生的口语交际和表达能力，夯实学生的语言基础，不断拓展学生的语言思维、提高学生语言能力，促进学生的自主发展和全面发展。本文中，笔者立足自身的语言训练实践经验，探索新课改下小学语文学生口语交际能力培养的有效对策。

This study was reviewed and approved by the Biomedical Research Ethical Committee of West China Hospital of Sichuan University (Approval No. 2020-29).

Anxiety and depression are common in geriatric patients with orthopedic trauma.Clinicians should remain vigilant of emotional disorders in geriatric patients and screen for anxiety and depression in higher risk groups.

Further investigations on larger samples are needed to confirm whether the results of our study are applicable on a broader scale.

The authors would like to thank the database manager for the technical support.