Rehabilitation pharmacotherapy: A combination of rehabilitation and pharmacotherapy

Abstract

Sarcopenia, malnutrition, and polypharmacy are major causes of frailty in older people. Some frail older people become disabled through stroke, pneumonia, hip fracture, and other diseases. Sarcopenia, malnutrition, and polypharmacy tend to worsen disability in older people. Rehabilitation pharmacotherapy and rehabilitation nutrition are important to improve frailty and disability in older people under these circumstances.

Polypharmacy, inappropriate prescribing, and adverse drug events are critical problems in a super‐aged society like Japan. Polypharmacy is one of the major causes of frailty in older people. Adverse drug events have happened in approximately 5% of acute care hospitalizations in older people, and polypharmacy defined as taking five or more medications was significantly associated with adverse drug events.1 In addition, 34.0% of older people who received regular home visiting services were taking at least one potentially inappropriate medication.2 Therefore, well‐designed interventional studies are required for polypharmacy and inappropriate prescribing to understand how to improve clinical outcomes.3

Polypharmacy and inappropriate prescribing recently have been drawing attention in the rehabilitation area. Among 144 stroke patients with chronic kidney disease in a convalescent rehabilitation ward, 48 (33.3%) patients took six or more drugs and were categorized into a polypharmacy group.4 Improvement of activities of daily living in the polypharmacy group, as assessed by the motor Functional Independence Measure efficiency, was significantly lower than in the nonpolypharmacy group.4 Moreover, taking potentially inappropriate medications as evaluated by the 2015 American Geriatrics Society Beers Criteria was independently and negatively correlated with motor Functional Independence Measure gain in older stroke patients in a convalescent rehabilitation ward.5 In addition, the use of anticholinergic drugs such as antipsychotics, antidepressants, and first‐generation antihistamines significantly increased from admission to discharge.5 These results indicate that polypharmacy and potentially inappropriate medications can worsen activities of daily living in older people who require rehabilitation. Therefore, a combination of rehabilitation and pharmacotherapy is important.

Rehabilitation pharmacotherapy is defined as helping people with disabilities and frail older people to achieve the highest possible body functions, activities, participation, and quality of life (QOL), using holistic evaluation by the International Classification of Functioning, Disability and Health (ICF), “pharmacotherapy in consideration of rehabilitation,” and “rehabilitation in consideration of pharmacotherapy.” It is a pharmacotherapy version of rehabilitation nutrition.6 The ICF has six components: health condition, body functions and structure, activities, participation, environmental factors, and personal factors. Drugs are included in the health condition component and relate to the body functions and structure, activities, and participation components of the ICF. The viewpoint of rehabilitation pharmacotherapy is crucial because most people with disabilities and frail older people receive pharmacotherapy, which can affect body functions and structure, activities, and participation. Rehabilitation pharmacotherapy is important to improve frailty and disability in people with disabilities and frail older people (Figure 1).

Figure 1.

Rehabilitation pharmacotherapy and the mechanisms for developing frailty and disability. Sarcopenia, malnutrition, and polypharmacy are major causes of frailty in older people. Some frail older people become disabled through stroke, pneumonia, hip fracture, and other diseases. Sarcopenia, malnutrition, and polypharmacy tend to worsen disability in older people. Rehabilitation pharmacotherapy and rehabilitation nutrition are important to improve frailty and disability in older people under these circumstances

“Pharmacotherapy in consideration of rehabilitation” includes medications to treat impairment, activity limitation, and participation restriction and also includes medication adjustment to reduce adverse drug events. For example, allopurinol and selective serotonin reuptake inhibitors may be effective for improving function further in people with disability. It is desirable to reduce polypharmacy as much as possible in terms of rehabilitation. However, appropriate polypharmacy may be necessary in stroke patients with hypertension, diabetes, and dyslipidemia.

“Rehabilitation in consideration of pharmacotherapy” is necessary in cases where medications are necessary for disease treatment but cause adverse drug events. For example, drug‐induced parkinsonism often occurs in patients with schizophrenia who are prescribed antipsychotic drugs. If prescriptions are adequate, rehabilitation for drug‐induced parkinsonism is necessary to achieve the highest possible body functions, activities, participation, and QOL. However, medication adjustment should be considered in all patients with drug‐induced parkinsonism.

There have been few cases where general and family physicians and pharmacists are deeply involved in both rehabilitation and pharmacotherapy. Rehabilitation and pharmacotherapy have been carried out separately in Japan. However, rehabilitation and pharmacotherapy should be applied simultaneously, because polypharmacy and potentially inappropriate medications can cause impairments such as dysphagia, cognitive impairment, and malnutrition in people with disabilities and frail older people. I expect that many general and family physicians and pharmacists, especially primary care‐certified pharmacists, are interested in rehabilitation pharmacotherapy.

CONFLICT OF INTEREST

The authors have stated explicitly that there are no conflicts of interest in connection with this article.