DOI: 10.1002/jgf2.163
EDITORIAL
Rehabilitation pharmacotherapy: A combination of rehabilitation and pharmacotherapy Polypharmacy,
drug
of rehabilitation pharmacotherapy is crucial because most people
events are critical problems in a super- aged society like Japan.
inappropriate
prescribing,
and
adverse
with disabilities and frail older people receive pharmacotherapy,
Polypharmacy is one of the major causes of frailty in older people.
which can affect body functions and structure, activities, and par-
Adverse drug events have happened in approximately 5% of acute
ticipation. Rehabilitation pharmacotherapy is important to improve
care hospitalizations in older people, and polypharmacy defined as
frailty and disability in people with disabilities and frail older people
taking five or more medications was significantly associated with ad-
(Figure 1).
1
verse drug events. In addition, 34.0% of older people who received
“Pharmacotherapy in consideration of rehabilitation” includes
regular home visiting services were taking at least one potentially
medications to treat impairment, activity limitation, and participa-
inappropriate medication. 2 Therefore, well-designed interventional
tion restriction and also includes medication adjustment to reduce
studies are required for polypharmacy and inappropriate prescribing
adverse drug events. For example, allopurinol and selective sero-
to understand how to improve clinical outcomes.
3
tonin reuptake inhibitors may be effective for improving function
Polypharmacy and inappropriate prescribing recently have been
further in people with disability. It is desirable to reduce polyphar-
drawing attention in the rehabilitation area. Among 144 stroke
macy as much as possible in terms of rehabilitation. However, ap-
patients with chronic kidney disease in a convalescent rehabilita-
propriate polypharmacy may be necessary in stroke patients with
tion ward, 48 (33.3%) patients took six or more drugs and were
hypertension, diabetes, and dyslipidemia.
categorized into a polypharmacy group.4 Improvement of activi-
“Rehabilitation in consideration of pharmacotherapy” is neces-
ties of daily living in the polypharmacy group, as assessed by the
sary in cases where medications are necessary for disease treat-
motor Functional Independence Measure efficiency, was signifi-
ment but cause adverse drug events. For example, drug-induced
4
cantly lower than in the nonpolypharmacy group. Moreover, tak-
parkinsonism often occurs in patients with schizophrenia who
ing potentially inappropriate medications as evaluated by the 2015
are prescribed antipsychotic drugs. If prescriptions are adequate,
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
F I G U R E 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
© 2018 The Authors. Journal of General and Family Medicine published by John Wiley & Sons Australia, Ltd on behalf of Japan Primary Care Association. J Gen Fam Med. 2018;1–2.
wileyonlinelibrary.com/journal/jgf2 | 1
|
EDITORIAL
2
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 physi-
ORCID Hidetaka Wakabayashi
http://orcid.org/0000-0002-0364-0818 Hidetaka Wakabayashi MD, PhD
Department of Rehabilitation Medicine, Yokohama City University Medical Center, Yokohama, Japan
cians and pharmacists are deeply involved in both rehabilitation and
E-mail:
[email protected]
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.
AC K N OW L E D G E M E N T S This work was not supported by any funding sources.
C O N FL I C T O F I N T E R E S T The authors have stated explicitly that there are no conflicts of interest in connection with this article.
REFERENCES 1. Fushiki Y, Kinoshita K, Tokuda Y. Polypharmacy and adverse drug events leading to acute care hospitalization in Japanese elderly. J Gen Fam Med. 2014;15:110–6. 2. Hamano J, Tokuda Y. Risk factors and specific prescriptions related to inappropriate prescribing among Japanese elderly home care patients. J Gen Fam Med. 2014;15:117–25. 3. Tokuda Y. Polypharmacy, inappropriate prescribing and adverse drug events in Japan. J Gen Fam Med. 2016;17:3–4. 4. Kose E, Maruyama R, Okazoe S, Hayashi H. Impact of polypharmacy on the rehabilitation outcome of Japanese stroke patients in the convalescent rehabilitation ward. J Aging Res. 2016;7957825:2016. 5. Kose E, Hirai T, Seki T, Hayashi H. Role of potentially inappropriate medication use in rehabilitation outcomes for geriatric patients after strokes. Geriatr Gerontol Int. 2017. https://doi.org/10.1111/ggi.13187. 6. Wakabayashi H. Rehabilitation nutrition in general and family medicine. J Gen Fam Med. 2017;18:153–4.
