Objective To ascertain the current burden of adverse drug reactions (ADRs) through a prospective analysis of all admissions to hospital. Design Prospective observational study. Setting Two large general hospitals in Merseyside, England. Participants 18 820 patients aged > 16 years admitted over six months and assessed for cause of admission. Main outcome measures Prevalence of admissions due to an ADR, length of stay, avoidability, and outcome. Results There were 1225 admissions related to an ADR, giving a prevalence of 6.5%, with the ADR directly leading to the admission in 80% of cases. The median bed stay was eight days, accounting for 4% of the hospital bed capacity. The projected annual cost of such admissions to the NHS is £466m (€706m, $847m). The overall fatality was 0.15%. Most reactions were either definitely or possibly avoidable. Drugs most commonly implicated in causing these admissions included low dose aspirin, diuretics, warfarin, and non-steroidal anti-inflammatory drugs other than aspirin, the most common reaction being gastrointestinal bleeding. Conclusion The burden of ADRs on the NHS is high, accounting for considerable morbidity, mortality, and extra costs. Although many of the implicated drugs have proved benefit, measures need to be put into place to reduce the burden of ADRs and thereby further improve the benefit:harm ratio of the drugs.

https://www.bmj.com/content/bmj/329/7456/15.full.pdf

Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients

This study updates and expands explicit criteria defining potentially inappropriate medication use by the elderly. Additional goals were to address whether adverse outcomes were likely to be clinically severe and to incorporate clinical information on diagnoses when available. These criteria are meant to serve epidemiological studies, drug utilization review systems, health care providers, and educational efforts. Consensus from a panel of 6 nationally recognized experts on the appropriate use of medication in the elderly was sought. The expert panel agreed on the validity of 28 criteria describing the potentially inappropriate use of medication by general populations of the elderly as well as 35 criteria defining potentially inappropriate medication use in older persons known to have any of 15 common medical conditions. Updated, expanded, and more generally applicable criteria are now available to help identify inappropriate use of medications in elderly populations. These criteria define medications that should generally be avoided in the ambulatory elderly, doses or frequencies of administrations that should generally not be exceeded, and medications that should be avoided in older persons known to have any of several common conditions.

Explicit Criteria for Determining Potentially Inappropriate Medication Use by the Elderly: An Update

Objective: To determine the evidence for physical therapy interventions aimed at improving functional outcome after stroke.Methods: MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, DARE, PEDro, EMBASE and DocOnline were searched for controlled studies. Physical therapy was divided into 10 intervention categories, which were analysed separately. If statistical pooling (weighted summary effect sizes) was not possible due to lack of comparability between interventions, patient characteristics and measures of outcome, a bestresearch synthesis was performed. This best-research synthesis was based on methodological quality (PEDro score).Results: In total, 151 studies were included in this systematic review; 123 were randomized controlled trials (RCTs) and 28 controlled clinical trials (CCTs). Methodological quality of all RCTs had a median of 5 points on the 10-point PEDro scale (range 2–8 points). Based on high-quality RCTs strong evidence was found in f...

The impact of physical therapy on functional outcomes after stroke: what's the evidence?

Background
Physical therapy (PT) is one of the key disciplines in interdisciplinary stroke rehabilitation. The aim of this systematic review was to provide an update of the evidence for stroke rehabilitation interventions in the domain of PT.

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What is the evidence for physical therapy poststroke? A systematic review and meta-analysis.

Stroke patients have impaired physical fitness and this may exacerbate their disability. It is not known whether improving physical fitness after stroke reduces disability. Objectives The primary aims were to establish whether physical fitness training reduces death, dependence and disability after stroke. The secondary aims included an investigation of the effects of fitness training on secondary outcome measures (including, physical fitness, mobility, physical function, health and quality of life, mood and the incidence of adverse events). Randomised controlled trials were included when an intervention represented a clear attempt to improve either muscle strength and/or cardiorespiratory fitness, and whose control groups comprised either usual care or a non-exercise intervention. A total of 12 trials were included in the review. No trials reported death and dependence data. Two small trials reporting disability showed no evidence of benefit. The remaining available secondary outcome data suggest that cardiorespiratory training improves walking ability (mobility). Observed benefits appear to be associated with specific or 'task-related' training.

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Physical fitness training for stroke patients

To determine the extent to which adverse drug reactions (ADRs) in elderly patients admitted to hospital are due to inappropriate prescribing, we examined 416 successive admissions of elderly patients to a teaching hospital. Interacting drug combinations and drugs with relative contra-indications (CIs) were common, but not as important in producing ADRs as drugs with absolute CIs or unnecessary drugs. Forty-eight patients (11.5% of admissions) were taking a total of 51 drugs with absolute CIs (3.8% of prescriptions). One hundred and seventy-five drugs were discontinued on or shortly after admission in 113 (27%) patients because they were deemed to be unnecessary. One hundred and three patients (27.0% of those on medication) experienced 151 ADRs of which 75 (49.7%) were due to drugs with absolute CIs and/or that were unnecessary, a significantly higher rate of ADRs (p less than 0.001) than observed for all prescriptions. Of 26 (6.3%) admissions attributed to ADRs, 13 (50%) were due to inappropriate prescriptions. The admission rate per prescription was significantly higher (p less than 0.001) for inappropriate than for appropriate drugs. We conclude that much drug-related morbidity in the elderly population may be avoidable, as it is due to inappropriate prescribing.

Inappropriate Medication is a Major Cause of Adverse Drug Reactions in Elderly Patients

Background cerebral multi-infarct states may lead to gait disorders in the absence of cognitive impairment. Where these gait disorders occur in the absence of neurological signs they have been termed gait apraxia or more recently higher-level gait disorders. In this paper we hypothesise three main types based on presumptive sites of anatomical damage: (a) Ignition Apraxia, where damage is predominantly in the supplementary motor area and its connections, with good responses to external clues; (b) Equilibrium Apraxia, where damage is predominantly in the pre-motor area in its connections, with poor responses to external cues and (c) Mixed Gait Apraxia. Subjects the clinical features and measured gait parameters of 13 patients with cerebral multi-infarct states and higher-level gait disorder are described (7 with Ignition Apraxia and 6 with Equilibrium Apraxia) along with those of 6 healthy elderly control subjects. Methods baseline gait characteristics were assessed on a walkway, which measured the following: step lengths, width of base and velocity. Results measured baseline gait parameters support the above hypothesis. Conclusions it is suggested, though not proven, that patients with Ignition Apraxia could have problems with internal cueing due to lesions in the supplementary motor area or its connections whereas those with Equilibrium Apraxia could have dysfunction predominantly in the pre-motor area and its connections.

A new classification of higher level gait disorders in patients with cerebral multi-infarct states

OBJECTIVES: to compare the therapeutic effects of two approaches to gait re-training--a schedule of conventional physiotherapy and treadmill re-training--in patients with higher-level gait disorders associated with cerebral multiinfarct states. DESIGN: single-blind crossover study involving a 4-week baseline period, 4 weeks of treadmill re-training and 4 weeks of conventional physiotherapy. SETTING: a large teaching hospital. SUBJECTS: patients with cerebral multi-infarct states who met the criteria for higher-level gait disorders. Computed tomographic brain scans showed at least one large vessel infarct, basal ganglia and white matter lacunes or extensive leukoaraiosis. INTERVENTIONS: a schedule of treadmill re-training and a specific schedule of physiotherapy containing 31 interventions in three treatment modules: (i) for gait ignition failure and turning; (ii) to improve postural alignment and enhance balance reactions; and (iii) for other components of cerebral multi-infarct state disordered gait. MAIN OUTCOME MEASURES: spatial and temporal gait measures and activity of daily living assessments. RESULTS: we recruited 18 patients, mean (SD) age 79.1 (6.8) years. Patients walked an average of 7.9 (5.5) km on the treadmill and had an average of 6.7 (3.2) h of physiotherapy. There were clinically moderate but highly statistically significant (P < 0.001) improvements in the following indices: time taken to complete the sit-to-stand test; time taken to walk 10 m; number of steps over 10 m; walking velocity; right and left step lengths; and time taken to complete the 'S' test. There were no differences in the results obtained in each limb of the study. CONCLUSION: there is no difference between the effects of conventional physiotherapy and treadmill re-training on the gait of patients with higher-level gait disorders associated with cerebral multi-infarct states. However, the improvements seen during the treatment period suggest that there is scope to improve the gait of this group of frail, elderly patients.

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Conventional physiotherapy and treadmill re-training for higher-level gait disorders in cerebrovascular disease.

Objective To evaluate the efficacy of intermittent pneumatic compression in treating oedema in the hemiplegic hand of stroke patients. Design Single-blind randomized control trial. Setting acute and rehabilitation elderly care wards in a teaching district. Subjects 37 Subjects with a first ever hemisphere stroke were randomized to treatment with standard physiotherapy either alone or combined with intermittent pneumatic compression. Main outcome measures The effect of treatment on oedema was assessed using measures of the hand volume of the hemiplegic hand. The impact on function was assessed using the motricity index. Results The treated group showed no change in the mean stroke hand volume. In the control group the mean stroke hand volume decreased by 3.2 ml. There was no statistically significant difference between the groups. The median scores for the motricity index increased for both groups but there was no significant difference between the groups and any improvement in motor function was independent of any treatment effects. Conclusion Intermittent pneumatic compression at the prescribed pressure and duration of this study is not an effective treatment for the oedematous stroke hand.

Intermittent compression for the treatment of the oedematous hand in hemiplegic stroke: a randomized controlled trial

OBJECTIVE: To assess the perception of angina in the elderly and its relationship to autonomic function.



DESIGN: Prospective cohort study of patients with exertional ischemia.



SETTING: Medical, geriatric and cardiac outpatient clinics in two centers.



PARTICIPANTS: All subjects had ischemic heart disease as evidenced by positive treadmill stress tests and, in some, diagnostic angiography and/or documented Q wave infarction. In the first study (I), 37 older patients (range 70–82 years) and 39 younger patients (range 42–59 years) were studied. In a subsequent study (II), a further 49 patients were divided into 2 groups: those with good perception of angina (Anginal Perception Threshold < 15 seconds, group A, 26 patients) and those with no angina despite ischemia (group B, 23 patients).



MEASUREMENTS: Anginal perceptual threshold (APT), age, cardiovascular autonomic function, and blood pressure were measured. APT was defined as the time between onset of 1 mm ST depression to the onset of angina during treadmill stress testing. Autonomic function was studied using heart rate ratios before and after the valsalva maneuver, heart rate responses to deep breathing, and heart rate and blood pressure responses to standing.



RESULTS: In study I, APT in the older patients was delayed by a median value of 49 seconds [79 (range 15–188) versus 30 (–99 to 97) seconds in the younger patients, P 30 seconds) was analyzed separately, there was a significant correlation between APT prolongation and impaired valsalva response (r = −0.4; P < 0.005).



In study II, 21 of 23 patients (91.3%) with positive exercise test but with no angina (group B) had at least one abnormal autonomic function test compared with 5 of 26 (19%) patients with good anginal perception (group A). Of note, group A was significantly younger than group B [60 (53–63) years vs 66 (62–70 years, P < 0.001].



CONCLUSION: Elevation of APT in the elderly suggests that warning of critical myocardial ischemia is delayed. Autonomic dysfunction may be one of the underlying mechanisms.

R C Tallis

Papers

Inappropriate Medication is a Major Cause of Adverse Drug Reactions in Elderly Patients

A new classification of higher level gait disorders in patients with cerebral multi-infarct states

Conventional physiotherapy and treadmill re-training for higher-level gait disorders in cerebrovascular disease.

Intermittent compression for the treatment of the oedematous hand in hemiplegic stroke: a randomized controlled trial

Silent Exertional Myocardial Ischemia in the Elderly: A Quantitative Analysis of Anginal Perceptual Threshold and the Influence of Autonomic Function