Psychotropic polypharmacy impairs walking independence in post-stroke patients

PURPOSE

Psychotropic drugs are associated with adverse outcomes in older adults. However, evidence on the effect of psychotropic use on walking ability in post-stroke patients is lacking. This study examined the association between psychotropic medication use and walking independence in post-stroke patients.

METHODS

This retrospective cohort study included stroke patients admitted for convalescent rehabilitation at a Japanese hospital between 2020 and 2022. Psychotropic medications (benzodiazepines, hypnotics, antipsychotics, and antidepressants) prescribed at admission were recorded. The primary outcome was walking independence at discharge, defined as a Functional Independence Measure (FIM) walk score ≥ 6. Logistic regression analyses examined the association between the number of psychotropic drugs and walking independence, adjusting for potential confounders.

RESULTS

Of the 709 patients enrolled, 559 (mean age 75.5 years, 52.8% male) were included in the analysis. At admission, 25.4% of patients used psychotropic drugs. In the adjusted analysis, the number of psychotropic medications was independently associated with lower walking independence at discharge (OR 0.620, 95% CI 0.428-0.897, P = 0.011). Hypnotic use specifically showed a negative impact on walking independence (OR 0.331, 95% CI 0.154-0.708, P = 0.004). However, psychotropic drug use was not significantly associated with improvement in FIM-motor scores.

CONCLUSION

Psychotropic polypharmacy at admission, particularly with hypnotics, was associated with reduced likelihood of achieving walking independence after stroke rehabilitation. Judicious use of psychotropic medications may be warranted when ambulation is a critical goal for older post-stroke patients.

Analysis of clinical pharmacists' interventions in a rehabilitation setting

Background

To elucidate the role of clinical pharmacists in rehabilitation programmes by examining the type, severity, medications involved, and the level of acceptance of pharmacists' interventions.

Methods

A cross-sectional study was conducted at the Qatar Rehabilitation Institute (QRI) in Doha, Qatar. Clinical pharmacists' interventions and their underlying rationales were categorised by the type of intervention using a validated classification system. The severity of these interventions was assessed using the National Patient Safety Agency (NPSA) Risk Matrix. Linear regression and chi-square analyses were employed to examine the relationships between patient-related and medication-related characteristics and the pharmacist interventions.

Results

A total of 3,807 clinical pharmacists' interventions involving 815 patients were collected and analysed. The majority of patients (n = 501, 61.5%) had three or more interventions. Findings indicated that most interventions were addressing pharmacological strategy (n = 1670, 43.9%) and drug quantity (n = 1166, 30.7%). The most frequently reported intervention subtypes included dose optimisation (n = 749, 19.7%), additional drug therapy (n = 673, 17.7%), and medication discontinuation (n = 476, 12.5%). Cardiovascular agents were involved in 37.1% of the interventions, followed by endocrine medications (17.1%) and centrally acting agents (11.7%). A significant proportion of interventions were deemed to have moderate severity (79.8%). Statistical analysis revealed a positive linear correlation between age and the number of interventions per patient (p < 0.001); with no significant difference in the severity of interventions between adult and elderly patients (p = 0.09).

Conclusion

This study highlights the diverse roles of clinical pharmacists in the rehabilitation field. The unique complexity of rehabilitation patients creates a challenging environment for clinical pharmacists, requiring adherence to fundamental practice principles while customising approaches to address individual patient needs. Further research is needed to assess the impact of these interventions on clinically significant outcomes.

Exploring the impact of anticholinergic burden on urinary independence: insights from a post-stroke cohort of older adults

BACKGROUND

Anticholinergic burden is associated with adverse events in the older adults. However, there is a lack of evidence regarding its effect on urinary independence in stroke patients.

AIM

This study examined the association between increased anticholinergic burden during hospitalization and urinary independence in post-stroke patients undergoing rehabilitation.

METHOD

This observational cross-sectional study included stroke patients admitted to a post-acute rehabilitation hospital between 2020 and 2022 who were not independently urinating. The degree of urinary independence was assessed using the Functional Independence Measure-Bladder (FIM-Bladder), a subscale of the motor domain of the FIM, and urinary independence was defined as FIM-Bladder ≥ 6. Anticholinergic burden was assessed using the anticholinergic risk scale (ARS), and changes in ARS during hospitalization were calculated by subtracting the value at admission from the value at discharge. The study outcome was urinary independence at discharge. Logistic regression analysis was used to examine whether change in ARS score was independently associated with the outcome. Statistical significance was set at P < 0.05.

RESULTS

Of the 573 patients enrolled, 312 patients (mean age 77.5 years, 51.9% male) were included in the analysis. ARS increased during hospitalization in 57 patients (18.3%). Change in ARS score was independently associated with urinary independence (odds ratio: 0.432, 95% confidence interval: 0.247-0.756, P = 0.003).

CONCLUSION

Increased anticholinergic burden in post-stroke patients who require assistance with urination is significantly associated with less independent urination. Anticholinergic agents may need to be introduced cautiously in patients who require assistance with urination.

Deprescribing psychotropic medications is associated with improvements in activities of daily living in post-stroke patients

AIMS

To examine the effect of deprescribing psychotropic medications on activities of daily living (ADLs) and swallowing function in patients undergoing convalescent rehabilitation following a stroke.

METHODS

In this retrospective cohort study, patients who underwent convalescent rehabilitation after a stroke were divided into two groups: deprescribing (number of psychotropic medications decreased during hospitalization) and non-deprescribing (number of psychotropic medications increased or remained unchanged). The primary outcome measure was ADLs assessed using the Functional Independence-Measured Motor Activity (FIM-motor) score at discharge. A multiple linear regression analysis was conducted to determine the independent association between deprescribing psychotropic medications and rehabilitation outcomes.

RESULTS

Of the 586 patients enrolled, 128 with a mean age of 74.1 ± 12.7 years were included in the final analysis after being prescribed psychotropic medications, with 36 of them (28.1%) in the deprescribing group. Multiple linear regression analysis revealed that deprescribing psychotropic medications was independently associated with FIM-motor function at discharge.

CONCLUSIONS

Deprescribing psychotropic medications is positively associated with improvements in ADLs among patients undergoing convalescent rehabilitation after a stroke. Geriatr Gerontol Int 2024; 24: 275-282.

Predictors of real-world adherence to prescribed home exercise in older patients with a risk of falling: A prospective observational study

Objectives

Using a multi-ethnic Asian population, this study assessed adherence to prescribed home exercise programs, explored factors predicting adherence, and evaluated whether home exercise adherence was associated with physical activity.

Methods

A prospective cohort study was conducted in 68 older adults (aged ≥65 years) from two geriatric outpatient clinics in Singapore, who were receiving tailored home exercises while undergoing 6 weeks of outpatient physical therapy for falls prevention. Adherence was measured as the percentage of prescribed sessions completed. Predictor variables included sociodemographic factors, clinical characteristics, intervention-specific factors, and physical and psychosocial measures. Multivariable linear regressions were performed to develop a model that best predicted adherence to prescribed exercise. Physical activity levels, measured by accelerometry, were analyzed by cross-sectional univariate analysis at 6 weeks.

Results

The mean adherence rate was 65% (SD 34.3%). In the regression model, the number of medications [B = 0.360, 95% CI (0.098-0.630)], social support for exercising [B = 0.080, 95% CI (0.015-0.145)], and self-efficacy for exercising [B = -0.034, 95% CI (-0.068-0.000)] significantly explained 31% (R 2 = 0.312) of the variance in exercise adherence. Older adults with better adherence took more steps/day at 6 weeks [B = 0.001, 95% CI (0.000-0.001)].

Conclusions

Low adherence to home exercise programs among older adults in Singapore, emphasizing the need for improvement. Counterintuitively, older adults with more medications, lower exercise self-efficacy, but with greater social support demonstrated higher adherence. Addressing unmet social support needs is crucial for enhancing adherence rates and reducing fall risks.

Polypharmacy and Its Association with Dysphagia and Malnutrition among Stroke Patients with Sarcopenia

Evidence on polypharmacy in patients with sarcopenia is lacking. We aimed to examine the association of polypharmacy with swallowing function and nutritional risk in post-stroke patient with sarcopenia. This retrospective cohort study included hospitalized patients diagnosed with sarcopenia who needed convalescent rehabilitation following stroke onset. Study outcomes were the Food Intake Level Scale (FILS) as dysphagia assessment and geriatric nutritional risk index (GNRI) as nutritional status at hospital discharge, respectively. To examine the impact of admission polypharmacy, multivariate linear regression analyses were used to determine whether the number of drugs prescribed at hospital admission was associated with these outcomes. As a result, of the 586 patients enrolled, 257 (mean age 79.3 years, 44.0% male) were diagnosed with sarcopenia and were finally analyzed high admission drug prescription numbers were independently associated with FILS (β = -0.133, p = 0.017) and GNRI (β = -0.145, p = 0.003) at hospital discharge, respectively. Polypharmacy is associated with dysphagia and malnutrition in post-stroke patients with sarcopenia. In addition to the combination of nutritional and exercise therapies, review and optimization of prescription medications may be warranted to treat sarcopenia in order to maximize improvement in outcomes for these patients.

Association of polypharmacy at hospital discharge with nutritional intake, muscle strength, and activities of daily living among older patients undergoing convalescent rehabilitation after stroke

Matsumoto A, Yoshimura Y, Shimazu S, Nagano F, Bise T, Kido Y, Shiraishi A, Sunahara T. Association of polypharmacy at hospital discharge with nutritional intake, muscle strength, and activities of daily living among older patients undergoing convalescent rehabilitation after stroke. Jpn J Compr Rehabil Sci 2022; 13: 41-48.

Objective

To investigate the association between polypharmacy at discharge and nutritional intake, muscle strength, and activities of daily living (ADL) among older patients undergoing convalescent rehabilitation after stroke.

Methods

This cross-sectional study involved hospitalized patients aged 65 or older who underwent convalescent rehabilitation after stroke. Polypharmacy was defined as the use of six or more medications. Study outcomes included energy intake, protein intake, handgrip strength (HG), and motor subscore of Functional Independence Measure (FIM-motor) at hospital discharge. Multiple linear regression analysis was used to examine the association between polypharmacy at discharge and outcomes.

Results

Of 361 eligible patients (mean [±SD] age, 78.3 ± 7.7 years; 49.3% male), 62.9% had polypharmacy. Multiple regression analysis revealed that polypharmacy at discharge was negatively associated with energy intake (β = -0.122, p = 0.003), protein intake (β = -0.133, p = 0.013), HG (β = -0.070, p = 0.022), and FIM-motor score (β = -0.069, p = 0.031) at discharge.

Conclusion

The impact of polypharmacy should be considered when designing nutritional management strategies for rehabilitation patients to maximize rehabilitation outcomes.

Polypharmacy and potentially inappropriate medications in stroke rehabilitation: prevalence and association with outcomes

Background Evidence is scarce regarding polypharmacy and potentially inappropriate medications (PIMs) in rehabilitation medicine. Aim To investigate the prevalence of polypharmacy and PIMs and their association with outcomes in stroke rehabilitation. Method A retrospective cohort study was conducted with 849 older inpatients post-stroke. Polypharmacy was defined as six or more medications, and PIMs were defined based on Beers criteria 2019. Study outcomes included functional independence measure (FIM)-motor, FIM-cognitive, energy intake, dysphagia, length of hospital stay, and the rate of home discharge. To consider the effect of pharmacotherapy during rehabilitation, multivariate analyses were used to determine whether the presence of polypharmacy or PIMs at discharge was associated with outcomes. Results After enrollment, 361 patients (mean age 78.3 ± 7.7 years; 49.3% male) were analyzed. Polypharmacy was observed in 43.8% and 62.9% of patients, and any PIMs were observed in 64.8% and 65.4% of patients at admission and discharge, respectively. The most frequently prescribed PIMs included antipsychotics, benzodiazepines, and proton pump inhibitors. Polypharmacy was negatively associated with FIM-motor score (β = - 0.062, P = 0.049), FIM-cognitive score (β = - 0.076, P = 0.014), energy intake (β = - 0.143, P = 0.005), and home discharge (OR: 0.458; 95% CI: 0.248, 0.847; P = 0.013). PIMs were negatively associated with home discharge (OR: 0.375; 95% CI: 0.195, 0.718; P = 0.003). Conclusion Polypharmacy and PIMs are commonly found among older patients undergoing stroke rehabilitation. Moreover, polypharmacy was negatively associated with activities of daily living (ADL) but not with PIMs and ADLs, and both were associated with home discharge.

Pharmacotherapy and the Role of Pharmacists in Rehabilitation Medicine

Pharmacotherapy is important in older patients undergoing rehabilitation because such patients, especially those with frailty and physical disabilities, are susceptible to drug-related functional impairment. Drug-related problems include polypharmacy, potentially inappropriate medications (PIMs), and potential prescription omissions. These problems are associated with adverse drug events such as dysphagia, depression, drowsiness, falls and fractures, incontinence, decreased appetite, and Parkinson's syndrome, leading to impaired improvement in activities of daily living (ADL), quality of life (QOL), and nutritional status. Moreover, the anticholinergic burden is associated with impaired physical and cognitive functions. Therefore, pharmacist-centered multidisciplinary pharmacotherapy should be performed to maximize rehabilitation outcomes. Pharmacotherapy includes a review of all medications, the assessment of drug-related problems, goal setting, correction of polypharmacy and PIMs, monitoring of drug prescriptions, and reassessment of drug-related problems. The goal of pharmacotherapy in rehabilitation medicine is to optimize drug prescribing and to maximize the improvement of ADL and QOL as patient outcomes. The role of pharmacists during rehabilitation is to treat patients as part of multidisciplinary teams and as key members of nutritional support teams. In this review, we aim to highlight existing evidence regarding pharmacotherapy in older adults, including drug-related functional impairment and the association between pharmacotherapy and functional, cognitive, and nutritional outcomes among patients undergoing rehabilitation. In addition, we highlight the important role of pharmacists in maximizing improvements in rehabilitation outcomes and minimizing drug-related adverse effects.

Comparison of Health Care Expenditures Among U.S. Older Adults With Pain Who Reported Frequent Exercise Versus Nonfrequent Exercise

This cross-sectional study included a nationally representative sample of U.S. adults aged ≥50 years with self-reported pain in the past 4 weeks from the 2018 Medical Expenditure Panel Survey. Adjusted linear regression analyses accounted for the complex survey design and assessed differences in several types of annual health care expenditures between individuals who reported frequent exercise (≥30 min of moderate-vigorous intensity physical activity ≥5 times per week) and those who did not. Approximately 23,940,144 of 56,979,267 older U.S. adults with pain reported frequent exercise. In adjusted analyses, individuals who reported frequent exercise had 15% lower annual prescription medication expenditures compared with those who did not report frequent exercise (p = .007). There were no statistical differences between frequent exercise status for other health care expenditure types (p > .05). In conclusion, adjusted annual prescription medication expenditures were 15% lower among older U.S. adults with pain who reported frequent exercise versus those who did not.

Association between different cutoff points for objectively measured moderate-to-vigorous physical activity and cardiometabolic markers in older adults

BACKGROUND

Regular moderate-to-vigorous physical activity (MVPA) is inversely associated with cardiovascular diseases in older adults. However, it remains unclear how the use of different cutoff points affects the associations with cardiovascular markers.

OBJECTIVE

To analyze the association between different cutoff points for objectively measured MVPA and cardiometabolic markers in older adults.

METHODS

This was a cross-sectional study involving 425 older adults (aged ≥60 years) from the EpiFloripa Ageing cohort study. We used ActiGraph accelerometers to measure MVPA in total minutes and in bouts (≥10 min) for at least 4 days. The tested cardiometabolic markers were waist circumference (WC), systolic blood pressure (SBP), diastolic blood pressure (DBP), high-density lipoprotein cholesterol (HDL-c), body mass index (BMI), triglycerides, fasting glucose and glycated hemoglobin (HbA1c). To identify MVPA, we used the cutoff points of Freedson et al. (≥ 1952 counts/min), Copeland and Esliger (≥ 1040 counts/min), and Troiano et al (≥ 2020 counts/min).

RESULTS

We observed significant differences in MVPA (total and bouts) between the different cutoff points (p < .001). The magnitude and number of associations between cardiometabolic markers and MVPA varied according to measurement units (total minutes: WC, SBP, DBP, HDL-c, BMI, triglycerides, glucose, and HbA1c versus bouts: WC, DBP, SBP HDL-c, and BMI) and cutoff points (higher associations for the Copeland and Esliger cutoff in total minutes and for the Troiano et al. cutoff in bouts of ≥10 min).

CONCLUSION

The use of different cutoff points in evaluating accelerometer-measured MVPA in older adults provides conflicting estimates, which emphasizes the importance of standardized thresholds.

Never Too Old for Cardiac Rehabilitation

Prevalence of cardiovascular disease (CVD) increases with age and is endemic in the burgeoning population of older adults. Older adults with CVD are susceptible not only to high mortality but also to increased likelihood of disability, dependency, functional decline, and poor quality of life. Cardiac rehabilitation (CR) is a multidimensional and comprehensive treatment program that can potentially address many of the distinctive challenges of older adults with CVD. In this review, the wide range of potential benefits of CR for older adults with CVD is summarized.