Rehabilitation Of The Older A... Health Article

Stroke-related dysphagia may cause complications, such as aspiration, dehydration, and nutritional deficiencies. In stroke patients, aspiration usually occurs from dysfunction of the pharyngeal phase of swallowing and is likely to occur without clinical manifestation, called “silent aspiration.” Nearly one third of patients with dysphagia have aspiration, which in addition to impaired cough and gag reflex, becomes a major risk factor for pneumonia. Formal evaluation of swallow function and compensatory strategies should be implemented before the initiation of any oral intake. Video fluoroscopic swallow study can reveal delayed initiation of swallow with alteration in pharyngeal transit time.

Elderly patients are particularly susceptible to the effects of dehydration and malnutrition. Dehydration may be due to lowered response, impaired ability to concentrate urine, use of diuretics, or decreased intake due to fear of incontinence. Malnutrition is most commonly related to depression followed by use of medications that decrease appetite. Age-related reduction in laryngeal elevation also increases risk of aspiration.

Communication disorders are present in more than one third of patients, with aphasia being the most common. Aphasia is a disorder of language, typically associated with lesions of the left or dominant hemisphere. It is also recognized that some aspects of language, such as prosody of speech, may be affected if the nondominant side is affected. The Boston School of Aphasia is a commonly used classification system that assesses fluency, comprehension, repetition, and word-finding ability to make a diagnosis. In addition, the Western Aphasia Battery is used to evaluate the severity of the impairment. Generally, the prognosis for recovery is worse for the patient with delayed treatment or with advanced age. Regardless, a speech-language pathologist can provide interventions to maximize recovery and prevent inappropriate compensatory strategies. Another important goal is the education of family, caregivers, and staff on the facilitation of communication to meet the patient's needs. Although drug therapy is unlikely to revolutionize the treatment of aphasia, it may serve to supplement intense treatment or strategies to improve performance. Trials using bromocriptine, amphetamines, piracetam, and donepezil have been promising [46,65–67]. Additional studies are necessary, however, to assess the full potential of aphasia pharmacotherapy. Until then, the initial severity of aphasia timeliness of therapy intervention and age are the main factors influencing speech recovery.

The incidence of bladder incontinence is 50% to 70% during the first month after stroke, but returns to the level of the general population by about 6 months. Supraspinal injury, as in stroke, causes an uninhibited or hyperreflexic bladder that is best treated with a timed voiding schedule. Postvoid residuals should be carefully monitored initially until safe bladder volume can be documented. Urinary retention is much less common, but may require intermittent catheterization initially. The frequency of urinary tract infections increases as a result of prolonged catheter use, alterations in bladder emptying, or reduced fluid intake. Elderly patients may have increased risk of bladder dysfunction due to premorbid bladder incontinence retention from medications, infections or prostatic problems in males. Bladder incontinence can increase skin breakdown, decrease socialization, increase rate of depression, and eventually increase chance of institutionalization. Medication should be used with caution unless previously indicated because of premorbid conditions.

Bowel incontinence occurs in up to one third of patients. Unlike bladder incontinence, bowel dysfunction usually resolves in the first few weeks after stroke. Even more common is bowel impaction. This is usually related to the relative inactivity; decreased nutrition, especially fiber; and diminished fluid intake. Appropriate dietary modifications, the use of regular bowel medications, and progressive increase in activity level can aid in managing bowel dysfunction.

Approximately 65% of individuals develop spasticity after a stroke [68]. In 1980, Lance [69] published this frequently cited definition: “Spasticity is a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyper-excitability of the stretch reflex, as one component of the upper motor neuron syndrome.” Treatment should be based on realistic goals for the patient, which may include reducing pain, simplifying activities of daily living, improving hygiene, or improving function. It is notable that some patients do not require treatment because they may rely on their spasticity for improved function (ie, “walk on their tone”).

Management of spasticity begins with two fundamental interventions: daily, prolonged stretching program; and avoidance or management of noxious stimuli (ie, ingrown toenail, distended bowel or bladder, pressure sore, or even tight clothing). It was once thought that a step-wise approach should be taken next, consisting of trial of oral medications, then local injections of phenol or botulinum toxin, to surgical options (rhizotomy, orthopedic surgery). The current management for spasticity of cerebral origin now minimizes the role of oral antispasticity agents because there is only mild reduction of spasticity with significant impairment of cognition. Even dantrolene, which is thought to act peripherally, may cause sedation and muscle weakness. The side effects of oral agents may be magnified in the elderly patient. Weight-bearing exercises and serial casting are commonly incorporated in the treatment program. Focal injections with phenol or botulinum toxin can be more effective when appropriately administered. Serial casting can and should be used adjunctively with other spasticity interventions. Intrathecal baclofen pumps are now more widely used for generalized spasticity [70]. Preliminary studies have shown intrathecal baclofen pumps to be effective in improving walking speed and functional mobility in ambulatory stroke patients when combined with physical therapy [71].

Hemiplegic shoulder pain is a frequent pain syndrome seen in poststroke patients with a prevalence of 34% to 84%, affecting both motor rehabilitation and psychologic well-being. It interferes with activities of daily living, balance, and ambulation and is associated with poorer outcome and increased length of stay in hospital [72]. Major risk factors for hemiplegic shoulder pain are advanced age, muscle tone changes after stroke, and sidedness of stroke. Age-related changes include decreased range of motion, degenerative changes of the acromioclavicular joint and glenoid labrum, and calcified tendons that may exacerbate the pain condition. Spastic hemiplegic shoulder is more commonly associated with pain compared with a flaccid shoulder because the humeral head is displaced anteriorly, posteriorly, or medially. Still, Tobis [73] in 1957 proposed the “main cause of shoulder pain in hemiplegia is flaccidity.” The weight of the unsupported arm stretches the capsule and ligaments causing inferior subluxation. Right-sided lesions are thought to cause increased risk of trauma-related hemiplegic shoulder pain, especially if associated with visuospatial deficits or neglect. The differential diagnosis of hemiplegic shoulder pain may include adhesive capsulitis, rotator cuff tears, neuropathic damage, chronic regional pain syndrome, and musculoskeletal imbalances. Clinical history, palpation, and plain radiographs with arms unsupported are reliable tools in making the diagnosis.

Treatment of hemiplegic shoulder pain starts with proper positioning and handling. There is evidence that hemiplegic shoulder pain increases during the first few weeks following discharge from a hospital, usually because of less skilled transfers, less therapy, and less medications [74]. Early range-of-motion exercises can prevent immobility, spasticity, and contracture. Slings and supports, if used appropriately, can reduce subluxation and protect from trauma; however, they also reduce upper-extremity mobility and sensory feedback, encourage flexor tone, and impair gait and body image. Functional electrical stimulation has been shown to maintain muscle bulk and tone in flaccid shoulder and enhance functional recovery through cortical feedback. More recently, intramuscular neuromuscular electric stimulation has been shown to reduce poststroke shoulder pain with improvement lasting at least 6 months [75]. Oral analgesic medications are limited by their cognitive and sedative side effects, especially in the elderly. Local steroid injections can provide temporary relief, but atrophic effects of repeated injections further weaken the cuff. In chronic regional pain syndrome, sympathetic nerve block of the stellate ganglion may be effective if more conservative measures fail. Botulinum toxin injections have been used to relieve hemiplegic shoulder pain at rest and with range-of-motion in some patients.

Stroke has been associated with a higher fall risk in both the acute care and rehabilitation settings [76–78]. The incidence of falls has been reported as 14% in acute care [79] , 24% during inpatient rehabilitation [78] , and 39% in geriatric rehabilitation setting [80]. These numbers are quite dramatic because the number of hospital falls in stroke patients is a strong predictor of falls after discharge. Studies have shown increased age, male gender, visuospatial neglect, right hemisphere strokes, urinary incontinence, bilateral motor involvement, postural instability, impaired activities of daily living, impulsivity, and use of certain medications (ie, diuretics, antidepressants, or sedatives) to be positively associated with fall risk [80–83]. Because rehabilitation has become an increasingly significant part of stroke care and falls are one of the most common complications, there is a unique obligation to work on fall prevention strategies without lowering activity levels. Fall prevention measures begin with a fall assessment screening to identify patients at risk, implementing fall prevention strategies that minimize the use of restraints and sedating medications, and making ongoing reassessments at scheduled intervals. Despite these interventions, falls remain a significant complication after stroke.

Poststroke depression is a frequent complication after stroke that is associated with a negative impact on rehabilitation and functional recovery [84–87]. Over the years, literature has supported a relationship between stroke and depression with an incidence between 15% and 70%. According to a population-based study, the prevalence of major depression was 25% at hospital discharge, 30% at 3 months after stroke, 16% at 1 year, and 29% at 3 years with a mean age of 73 [88]. The Framingham study reported a 47% incidence of depression at 6 months poststroke with no difference between left- and right-sided lesions [89]. Other studies reported predisposition to depression after left anterior or right posterior infarcts [90]. The pathophysiology is not entirely elucidated and might involve several mechanisms including direct consequences of brain lesions, neuroendocrine mechanism, or even psychologic reaction to the stress or disability. Other causes include damage to left cerebral cortex, proximity of lesion to frontal pole, and premorbid history of a psychiatric disorder. Confounding factors may include medical comorbidities, impaired attention and initiation, or drugs that may depress mood (Table 3 ).

Treatment should be comprehensive to include patient and caregiver education, therapeutic exercises, psychotherapy, and pharmacologic agents. Counseling during rehabilitation may decrease the risk of depression, especially when directed toward concerns of being a burden on family or society. Several drugs have been shown to be effective in treating depression with a potential benefit of improving short-term motor recovery after stroke [91]. Currently, such drugs as methylphenidate, nortriptyline, citalopram, and fluoxetine are commonly used to treat poststroke depression [92,93].

The search for depression should be systematic and early to ensure appropriate treatment. The elderly population may already be at high risk for depression because of associated chronic disease. Even more, advanced age is often accompanied by loss of key social support systems because of the death of a spouse or siblings, retirement, or relocation of residence at a time when it is most needed. Older adults with depression are more likely to commit suicide than are younger people with depression. Within 10 years after a stroke, the risk of death is 3.5 times higher in depressed patients than in those without depression [94].

A comprehensive rehabilitation program should include appropriate community and social integration. A history of the patient's prior community activities and interests serves to guide the clinician in planning appropriate measures. The poststroke family support, financial status, and community resources should be evaluated to optimize successful return to the community. There are both physical and cognitive benefits associated with community participation. It has been shown that participation in physical activities can improve a patient's balance, decrease anxiety and depression, assist with pain management, and increase one's ability to maintain functional independence [95]. There is also a potential decreased risk of dementia with certain leisure activities [96].

The ability to drive is a vital aspect of maintaining functional independence in the community. Although many older adults voluntarily stop driving, there are still several elderly patients who wish to resume. The elderly are the fastest growing segment of the driving population. A person's crash risk per mile increases starting at age 55, exceeding that of a young, beginning driver by age 80 [97]. The effect of adding disability to these statistics is obvious. Counseling patients about their new disability and discussing alternative options may be appropriate. Driving assessment can be coordinated through a multidisciplinary driver's rehabilitation program, which may include an assessment of vision, attention, hearing, visuospatial skills, and motor function, followed by a behind-the-wheel assessment [98]. Opinions on driving fitness may be required by the physician; current licensing policies, liability, and reporting procedures for potentially ineligible drivers should be reviewed for each state [99].