Anxiety and depression status in geriatric patients undergoing total hip arthroplasty: Correlation with postoperative pain and risk factors

Abstract

BACKGROUND

Anxiety, depression, and postoperative pain are common in patients with hip joint disorders and are associated with compromised functional outcomes and delayed recovery.

AIM

To investigate the prevalence of anxiety and depression among geriatric patients who underwent total hip arthroplasty (THA), explored their association with postoperative pain, and identified contributing risk factors.

METHODS

A total of 111 geriatric patients who underwent THA between January 2021 and January 2024 were included. Standardized psychological assessment tools-including the Zung Self-Rating Anxiety Scale (SAS) and the Zung Self-Rating Depression Scale (SDS)-and the Numeric Rating Scale (NRS) for pain quantification were systematically administered. Pearson correlation analysis was utilized to explore the relationships among SAS, SDS, and NRS scores. Univariate and multivariate binary logistic regression analyses were conducted to identify risk factors for anxiety and depression in these patients.

RESULTS

The cohort exhibited moderate anxiety (SAS: 44.23 ± 9.03), mild depression (SDS: 46.98 ± 9.15), and moderate postoperative pain (NRS: 4.93 ± 2.37). Patients with anxiety or depression reported significantly higher NRS scores than those without these conditions. Significant positive correlations were observed between SAS and SDS scores, as well as between each of these and NRS scores. Univariate analysis revealed that gender, age, disease duration, alcohol use, diabetes history, and NRS scores were significantly associated with anxiety and depression. Multivariate analysis further identified female gender, disease duration ≥ 2 years, alcohol use, and NRS scores ≥ 5 as independent predictors of postoperative psychological distress.

CONCLUSION

Anxiety and depression are closely linked with postoperative pain in geriatric patients post-THA recovery. Early psychological screening and multimodal pain management strategies are recommended-particularly for individuals with a disease duration of ≥ 2 years, a history of alcohol consumption, or an NRS score of ≥ 5, as well as female patients-to effectively mitigate their negative emotional states and improve postoperative recovery.

Key Words: Total hip arthroplasty; Geriatric patients; Anxiety and depression; Postoperative pain; Risk factors

Core Tip: Poor functional and recovery outcomes in patients with hip disorders are often linked to anxiety, depression, and postoperative pain. However, research identifying how anxiety and depression influence pain after total hip arthroplasty (THA) in older patients or their potential determinants is limited. Our findings indicate that a subset of older patients with THA experience anxiety and depression, which correlate with elevated levels of postoperative pain. Clinicians should closely monitor female patients, individuals with long-standing hip disease, alcohol consumers, and patients with high pain scores (assessed using the Numeric Rating Scale), as these groups are at a greater risk of psychological distress.

INTRODUCTION

Hip fractures are a major geriatric health concern associated with high mortality rates, disability, numerous complications, and substantial healthcare expenditures[1]. Epidemiological models project a sharp increase in global incidence, with cases expected to reach 2.6 million by 2025 and 4.5 million by midcentury due to population aging[2]. Total hip arthroplasty (THA), a prevalent surgical approach for hip fractures in older adults, is one of the most effective orthopedic interventions, with over 1 million procedures performed annually worldwide to replace damaged joints[3]. Evidence consistently shows that THA significantly reduces pain and improves function[4,5]. However, a subset of patients experience suboptimal outcomes, and increasing research highlights the role of psychological factors—particularly anxiety disorders and depression—as significant contributors to poor recovery trajectories[6]. The perioperative impact of such psychological comorbidities has been increasingly documented in prospective studies. A systematic review of THA recipients revealed that preoperative depression and anxiety were associated with worse postoperative pain, delayed functional recovery, and more complications, suggesting that these psychological conditions may compromise treatment efficacy and recovery[7]. Similar trends have been observed in total knee arthroplasty (TKA), in which depressive symptoms are associated with worse pain relief and increased disability risk[8]. More broadly, anxiety, depression, and postoperative pain contribute to poorer functional outcomes and worsening of hip joint disorders following treatment[9]. Additional studies associated depression and anxiety with increased risks of postoperative infections, revision surgery, and reoperation in patients who had undergone THA and TKA[10]. Anxiety and depression are typically associated with diminished quality of life and pain induced by the disease and surgical procedures[11]. Despite their clinical relevance, few studies have specifically explored the prevalence of anxiety and depression, their relationship with postoperative pain, or associated risk factors in older THA populations. Our study addresses this knowledge gap by combining comprehensive psychological assessments with multivariate analyses. The objectives were to quantify the prevalence of anxiety and depression, examine their correlation with postoperative pain, identify high-risk subgroups using logistic regression, and propose targeted intervention strategies. These efforts aim to optimize clinical outcomes, rehabilitation success, and overall prognosis in this vulnerable population.

MATERIALS AND METHODS

Study population

This retrospective study included 111 older patients who underwent THA at The First People’s Hospital of Changde City between January 2021 and January 2024.

Inclusion criteria: (1) A diagnosis of hip pathology requiring THA following established clinical guidelines[12]; (2) Classification as American Society of Anesthesiologists physical status I or II[13]; (3) Availability of complete medical records; and (4) The presence of intact cognitive function and effective communication ability.

Exclusion criteria: (1) Chronic use of analgesics or sedative medications; (2) A history of substance abuse or alcohol dependence; (3) Known hypersensitivity to anesthetic or analgesic agents; (4) Obesity [body mass index (BMI) ≥ 30 kg/m²]; (5) Uncontrolled hypertension with elevated intraocular pressure; (6) Significant dysfunction of major organs; and (7) Documented symptoms of preoperative anxiety and depression.

Postoperative analgesia management

Postoperative pain was managed using intravenous (IV) patient-controlled analgesia with either Fentanyl (20 μg/mL) or Hydrocodone (0.2 mg/mL). The patient-controlled analgesia protocol included a basal infusion of 1 mL/hour, incremental doses of 0.5 mL, and an 8-minute lockout period. Parecoxib sodium (40 mg IV) was administered twice daily to patients without renal impairment. For those with contraindications to nonsteroidal anti-inflammatory drugs (NSAIDs), IV acetaminophen (1 g every 6 hours) was used as an alternative.

Data collection and outcome assessment

Anxiety and depression evaluation: Anxiety and depressive symptoms were assessed using the validated Zung Self-Rating Anxiety Scale (SAS) and the Zung Self-Rating Depression Scale (SDS)[14]. SAS is a 20-item instrument rated on a 4-point Likert scale (1–4 points). Raw score was converted to a standardized index score (raw sum × 1.25), with higher scores indicating greater symptom severity. Severity classification for both scales was as follows: (1) < 50 (normal); (2) 50–59 (mild); (3) 60–69 (moderate); and (4) ≥ 70 (severe). The SDS follows the same structure, scoring algorithm, and severity thresholds as the SAS.

Postoperative pain assessment: Postoperative pain was evaluated using the Numeric Rating Scale (NRS)[15], an 11-point metric in which 0 denotes no pain, 1–3 indicates mild discomfort, 4–6 represents moderate pain, and 7–10 reflects severe pain.

Clinical data collection: Demographic and clinical data were systematically collected for statistical analysis. Variables included demographic characteristics (sex, age, and BMI), disease-related parameters (duration and affected side), lifestyle factors (smoking and alcohol consumption), comorbidities (e.g., diabetes mellitus), and pain scores (NRS). These variables were analyzed using both univariate and multivariate regression modeling to identify significant predictors of anxiety and depression.

Statistical analysis

Continuous variables were expressed as mean ± SE, and intergroup comparisons were conducted using independent-samples t-tests. Categorical variables were reported as frequencies (percentages) and analyzed using Pearson’s χ² tests. All statistical analyses were performed using IBM Statistical Package for the Social Sciences Statistics (version 20.0) and GraphPad Prism 7. Pearson’s product-moment correlation coefficients were used to examine the relationships among anxiety (SAS), depression (SDS), and pain intensity (NRS). Potential risk factors contributing to anxiety and depression were investigated through univariate analyses followed by multivariate binary logistic regression modeling to identify independent predictors. Statistical significance was established at α = 0.05.

RESULTS

Anxiety–depression status and postoperative pain

Among the 111 older patients who underwent THA, the mean standardized SAS score was 44.23 ± 9.03. Psychological evaluation revealed that 74.77% of the participants showed no clinically significant anxiety symptoms. Among those with anxiety symptoms, most were classified as mild cases, with a limited number presenting moderate symptoms. Notably, no cases of severe anxiety were observed in this patient population. The mean SDS score for depressive symptoms was 46.98 ± 9.15, with 66.67% of the participants falling within the normal range. Among those with depressive symptoms, mild cases were the most common, followed by moderate cases, while severe depression was absent from our study cohort. Pain evaluation using the NRS produced a mean score of 4.93 ± 2.37, indicating that most patients experienced some degree of postoperative discomfort. Pain was most frequently rated as moderate, while fewer patient cases reported either severe or mild pain. Only two individuals (1.80%) reported no postoperative pain. These findings are illustrated in Figure 1 and presented in Table 1.

Figure 1 Anxiety and depression status as well as postoperative pain in elderly total hip arthroplasty patients. A: The prevalence and severity of anxiety symptoms; B: The occurrence and intensity of depressive symptoms; C: The gradation of postoperative pain experiences.

Table 1 Anxiety and depression status as well as postoperative pain in elderly patients undergoing total hip arthroplasty.

Factors	Scores
Zung Self-Rating Anxiety Scale	44.23 ± 9.03
Zung Self-Rating Depression Scale	46.98 ± 9.15
Numeric Rating Scale	4.93 ± 2.37

Postoperative pain levels in patients with anxiety and depression

Our analysis of 111 older patients who underwent THA revealed clinically significant findings regarding psychological status and pain perception. The prevalence of anxiety and depression was 25.23% and 33.33%, respectively. Comparative analysis revealed that patients with anxiety and depression reported significantly higher postoperative pain levels, as measured by the NRS scores (P < 0.01), compared to their nonaffected counterparts (Figure 2).

Figure 2 Postoperative pain levels categorized by psychological status (anxiety vs non-anxiety, depression vs non-depression). A: Numeric Rating Scale (NRS) scores in anxious (5.64 ± 2.08 points) vs non-anxious (4.11 ± 2.33 points) patients; B: NRS scores in depressed (6.19 ± 2.32 points) vs non-depressed (4.08 ± 2.12 points) patients. ^bP < 0.01. NRS: Numeric Rating Scale.

Correlational analysis of psychological measures and pain intensity

Pearson correlation analysis yielded significant positive relationships between SAS and NRS scores, SDS and NRS scores, and SAS and SDS scores (P < 0.001; Table 2).

Table 2 Correlations among Zung Self-Rating Anxiety Scale, Zung Self-Rating Depression Scale, and Numeric Rating Scale.

Factors	r	P value
SAS vs NRS	0.360	< 0.001
SDS vs NRS	0.335	< 0.001
SAS vs SDS	0.395	< 0.001

NRS: Numeric Rating Scale; SAS: Zung Self-Rating Anxiety Scale; SDS: Zung Self-Rating Depression Scale.

Univariate analysis of risk factors for anxiety and depression in older the patients

Patients were categorized into two groups based on psychological assessment scores: (1) Anxiety/depression (SAS ≥ 50 or SDS ≥ 50; n = 62); and (2) Nonanxiety/depression (SAS < 50 and SDS < 50; n = 49). Univariate modeling assessed various variables, including sex, age, BMI, disease duration, educational level, affected side, smoking history, alcohol consumption history, diabetes history, and NRS pain scores. Significant associations with anxiety and depression were identified for sex, age, disease duration, alcohol consumption history, diabetes history, and NRS (P < 0.05). Detailed results of the univariate analysis are presented in Table 3.

Table 3 Univariate analysis of risk factors for anxiety and depression in elderly total hip arthroplasty patients, n (%).

Factors	n	Anxiety/depression group (n = 62)	Non-anxiety/depression group (n = 49)	χ2	P value
Gender				4.749	0.029
Male	44	19 (30.65)	25 (51.02)
Female	67	43 (69.35)	24 (48.98)
Age (years)				4.524	0.033
< 60	40	17 (27.42)	23 (46.94)
≥ 60	71	45 (72.58)	26 (53.06)
Body mass index (kg/m2)				0.103	0.749
< 24	54	31 (50.00)	23 (46.94)
≥ 24	57	31 (50.00)	26 (53.06)
Disease duration (years)				5.412	0.020
< 2	73	35 (56.45)	38 (77.55)
≥ 2	38	27 (43.55)	11 (22.45)
Educational level				0.148	0.700
< junior high school	68	37 (59.68)	31 (63.27)
≥ junior high school	43	25 (40.32)	18 (36.73)
Affected site				1.014	0.314
Left hip	44	22 (35.48)	22 (44.90)
Right hip	67	40 (64.52)	27 (55.10)
Smoking history				0.369	0.544
None	69	37 (59.68)	32 (65.31)
Yes	42	25 (40.32)	17 (34.69)
Alcohol consumption history				7.382	0.007
None	61	27 (43.55)	34 (69.39)
Yes	50	35 (56.45)	15 (30.61)
Diabetes history				5.310	0.021
None	86	43 (69.35)	43 (87.76)
Yes	25	19 (30.65)	6 (12.24)
Numeric Rating Scale (points)				6.190	0.013
< 5	51	22 (35.48)	29 (59.18)
≥ 5	60	40 (64.52)	20 (40.82)

Multivariate analysis of risk factors for anxiety and depression in older the patients

Comprehensive multivariate logistic regression analysis, incorporating all significant variables from the univariate analysis (with variable coding detailed in Table 4), identified several independent predictors of anxiety and depression in older THA patients. The final adjusted model revealed that female gender, longer disease duration, alcohol consumption history, and higher postoperative NRS pain scores were statistically significant independent risk factors for psychological distress (P < 0.05; Table 5).

Table 4 Variable assignments.

Factors	Variable	Assignment
Gender	X1	Male = 0, female = 1
Age (years)	X2	< 60 = 0, ≥ 60 = 1
Disease duration (years)	X3	< 2 = 0, ≥ 2 = 1
Alcohol consumption history	X4	None = 0, yes = 1
Diabetes history	X5	None = 0, yes = 1
Numeric Rating Scale (points)	X6	< 5 = 0, ≥ 5 = 1

Table 5 Multivariate analysis of risk factors for anxiety and depression in elderly total hip arthroplasty patients.

Factors	β	SE	Wald	P value	Odds ratio	95%CI
Gender	1.143	0.473	5.825	0.016	3.135	1.240-7.927
Age (years)	0.835	0.475	3.095	0.079	2.306	0.909-5.848
Disease duration (years)	1.034	0.496	4.345	0.037	2.812	1.064-7.434
Alcohol consumption history	1.216	0.466	6.807	0.009	3.375	1.353-8.417
Diabetes history	1.074	0.588	3.338	0.068	2.927	0.925-9.260
Numeric Rating Scale (points)	1.029	0.684	5.158	0.023	2.797	1.151-6.794

DISCUSSION

Current evidence indicates that mood disorders commonly cooccur with joint replacement procedures, presenting substantial clinical challenges. Patients undergoing total joint arthroplasty often experience concurrent anxiety and depression, which have been linked to increased healthcare costs and a higher risk of surgical complications[16]. Notably, approximately 30.0% of patients who undergo hip replacement suffer from prolonged postoperative pain, which can significantly delay rehabilitation and exacerbate mood disorders through pain-related mechanisms[17]. This study specifically examined geriatric individuals who underwent THA, assessing the prevalence of psychological symptoms, postoperative pain levels, and their mutual relationships, aiming to enhance treatment strategies for this vulnerable population.

The study produced several important observations regarding psychological health in older patients with arthroplasty. An initial analysis revealed that 25.23% of the 111 participants met the criteria for anxiety symptoms, while 33.33% exhibited signs of depression. Most symptoms were mild, but even mild psychological distress could negatively affect recovery and warrant clinical attention. These prevalence rates are consistent with previous research—including a study by Duivenvoorden et al[18], which reported similar rates of 27.9% for anxiety and 33.6% for depression in comparable patient populations. Additionally, only 2 (1.8%) patients reported no postoperative pain (NRS = 0), aligning with prior data showing that 2%–4% of patients are pain-free post-THA[19]. Although the use of analgesics has potentially masked the relationships between pain and anxiety/depression, significant differences in NRS scores between groups confirm the robustness of this relationship. Hence, subsequent investigations may consider implementing short-term analgesic withdrawal (“drug holidays”) to refine assessments. Further examination revealed that moderate discomfort represented the most frequently reported pain level, with individuals experiencing anxiety or depression consistently reporting higher pain scores compared to those without mood disturbances. This aligns with findings by Ghoshal et al[20], who established that heightened anxiety and depression scores were associated with an increased likelihood of persistent postoperative pain in patients who underwent TKA and THA. Additional evidence from population-level studies has demonstrated consistent associations between chronic pain conditions (arthritis, migraines, and back pain) and various mental health disorders (depression, panic attacks, and generalized anxiety disorder)[21]. Evidence implicates the protein kinase C zeta/protein kinase M zeta–glutamate receptor 1 axis in mediating pain-related anxiety, whereas the phosphoinositide 3-kinase–mechanistic target of the rapamycin signaling pathway potentially underlies depressive and anxiety-like behaviors in pain-related conditions[22]. These molecular pathways may collectively contribute to the interplay between psychological distress and pain intensity. Meanwhile, heightened anxiety correlates with increased expression of the cellular FBJ murine osteosarcoma viral oncogene homolog (c-Fos) protein in the basolateral and central amygdala, potentially intensifying pain signaling and contributing to a maladaptive pain–anxiety cycle[23]. Additionally, cytokines released following THA—such as interleukin (IL)-6, IL-8, and IL-10—may further modulate this anxiety–pain interaction[24,25]. In our study, correlation analysis demonstrated strong positive correlations between anxiety levels (SAS), depressive symptoms (SDS), and reported pain severity (NRS). These results are consistent with prior osteoarthritis research that also reported significant relationships between pain experience and psychological factors[26]. Furthermore, a bifactor model analysis from previous studies indicated a significant positive correlation between anxiety and depression, both of which were positively correlated with pain intensity—mirroring the relationships observed in our study[27]. These relationships may stem from shared psychological mechanisms that influence both emotional stress and physical discomfort[28].

Univariate analysis identified several factors significantly associated with anxiety and depression in older patients who underwent THA, including sex, age, disease duration, alcohol consumption history, diabetes history, and NRS scores. Subsequent multivariate regression analysis confirmed that female sex, prolonged disease duration (≥ 2 years), alcohol consumption history, and higher NRS scores (≥ 5) were independent predictors of anxiety and depressive symptoms in this population. These findings are consistent with prior research. Nickinson et al[29] reported that female patients and individuals with a history of lower limb joint replacements were at elevated risk of developing postoperative depression following orthopedic procedures. Similarly, Wilson et al[30] found that new-onset depression after total joint arthroplasty was associated with younger age, preexisting psychological comorbidities, hospital readmission within 6 months after surgery, and opioid use—whether initiated preoperatively, postoperatively, or continued from the preoperative into the postoperative period. The increased prevalence of anxiety and depression among females may be attributed to cerebral morphology, genetic predisposition, and hormonal fluctuations[31]. An extended illness duration (≥ 2 years) correlates with extended disease-related suffering and accumulated psychological distress, which may increase susceptibility to mood disorders[32]. Alcohol consumption history has been linked to elevated monocyte chemoattractant protein-1 concentrations, a cytokine known to impair sleep quality and predispose individuals to anxiety and depression[33]. Moreover, chronic alcohol exposure can induce neuroadaptive changes, including modifications in gamma-aminobutyric acid, dopamine, and glutamate levels, potentially disrupting the structure and function of the central nervous system and destabilizing mood regulation[34]. Severe postoperative pain (NRS ≥ 5) can hinder recovery, disrupt daily functioning and sleep, and significantly increase the risk of anxiety and depression[35]. These findings support the need for a multimodal, tiered approach to pain management tailored to individual pain intensities. For patients with mild pain (NRS < 5), basic analgesics (e.g., acetaminophen or low-dose NSAIDs) supplemented by psychological support (e.g., preoperative education and mindfulness-based relaxation techniques) are recommended. In contrast, patients reporting moderate to severe pain (NRS ≥ 5) may benefit from an escalated analgesic regimen (e.g., NSAIDs plus weak opioids) and adjunctive dual-action antidepressants (e.g., duloxetine or vortioxetine for analgesic and anxiolytic benefits)[36,37].

Several limitations should be acknowledged. First, the retrospective study design precludes the ability to draw strong causal inferences. Prospective longitudinal studies are needed to clarify the directional relationship between anxiety, depression, and pain. Second, single-center sampling introduces potential geographical selection bias, limiting generalizability. Multicenter collaborations and a larger sample size are needed to enhance data validity. The long-term effects of multimodal analgesia on psychological outcomes require prospective verification through longer-term follow-up.

CONCLUSION

A subset of older patients who underwent THA experienced comorbid anxiety and depression, which frequently coincided with heightened postoperative pain. Effective management should prioritize personalized pain control as the foundation, supplemented by tailored psychological support. Additionally, special attention should be given to high-risk groups—especially female patients, those with prolonged disease durations, a history of alcohol consumption, and elevated pain scores. Proactive measures—including lifestyle interventions (e.g., alcohol cessation) and optimized multimodal analgesia—should also be implemented to minimize psychological distress in these individuals. These insights facilitate the early identification and comprehensive management of vulnerable patients and inform evidence-based interventions, ultimately improving mental health outcomes in older THA populations.