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Increasing Stroke Patients' Success in Self-Medication Programs Using an Interdisciplinary Cognitive Rehabilitation Approach
Rehabilitation programs strive to help patients become more independent in all aspects of daily living. Therefore, management of a patient’s healthcare requirements should be an integral part of the rehabilitation program, including management of medications. Some rehabilitation programs implement self-medication programs (SMP); however, patients with cognitive deficits are often excluded. This study explored whether patients with cognitive deficits due to stroke could successfully complete an SMP using an interdisciplinary cognitive rehabilitation approach. Twenty-seven stroke patients and 36 debilitated patients with cognitive deficits participated in an SMP. A nurse and a pharmacist educated patients on their medications, and a speech-language pathologist provided cognitive rehabilitation to the stroke patients, which incorporated information from the SMP. Eighty-one percent of the stroke patients successfully completed the SMP, compared to 36% of the debilitated patients. Thus, an interdisciplinary approach to medication management for cognitively impaired stroke patients holds promise.
Rehabilitation programs strive to help patients become more independent in all aspects of daily living. In addition to activities related to self-care (e.g., ambulation, dressing, hygiene), management of a patient’s healthcare requirements should be an integral part of the rehabilitation program. This includes management of medications, since adherence to medication schedules is paramount for achieving optimal health-related outcomes (Hutchison, Jones, West, & Wei, 2006).
Self-medication programs (SMPs) have been implemented in some rehabilitation programs to increase patient knowledge and independence in medication management (Kelly, 1994; Maddigen, Farris, Keating, Wiens, & Johnson, 2003; Pereles, Romonko, Murzyn, Hogan, Silvius, & Stokes, et al., 1996; Schepers, Won, Bieliauskas, Galecki, & Hogikyan, 2000). However, the level of success in these programs has varied.
Numerous studies have been conducted to determine which patients are more likely to succeed in an SMP. Schepers and colleagues (2000) used a neuropsychological test battery with patients in a long-term care facility to determine variables that may predict success. Although no one specific variable held significant predictive value, it was determined that the absence of a diagnosis of stroke, depression, or a specific anxiety disorder tended to predict success. Maddigen and colleagues (2003) performed a retrospective review of charts from 301 patients in a rehabilitation hospital who participated in an SMP. Using a logistic regression model, they found that cognition and medication regimen complexity were important predictors of medication management capacity. Pereles and colleagues (1996) found that participation in an SMP improved compliance with medications, but did not necessarily improve patients’ knowledge of medications or ability to self-medicate upon discharge from the hospital. Again, cognitive deficits were cited as a cause of limited success.
Indeed, cognitive deficits have been cited as a primary deterrent for success with medication management for several populations, including individuals with HIV (Albert, Flater, Clouse, Todak, Stern, & Marder, 2003; Albert, Weber, Todak, Polanco, Clouse, & McElhiney, et al., 1999); schizophrenia (Corrigan, Wallace, Schade, Green, 1994), and even for healthy, elderly individuals living in the community (Branin, 2001; Hutchison, et al., 2006).
There is substantial evidence to support the benefit of cognitive rehabilitation for individuals with memory and attention deficits resulting from stroke and traumatic brain injury (Carney, Chesnut, Maynard, Mann, Patterson, & Helfand, 1999; Cicerone, Dahlberg, Malec, Langenbahn, Felicetti, & Kneipp, et al., 2005; Park & Ingles, 2001). However, although it is understood that cognitive deficits negatively impact successful medication management, the potential benefit of cognitive rehabilitation in relation to learning medication schedules had not been explored. The purpose of this study was to determine whether cognitive rehabilitation for patients with cognitive deficits due to a stroke would benefit from an SMP led by an interdisciplinary team consisting of the rehabilitation nurse, pharmacist, and speech-language pathologist. It was hypothesized that patients with mild to moderate cognitive deficits who received individualized cognitive rehabilitation would successfully complete the program.
This study used a preexperimental posttest only comparative group design, which examined the effect of cognitive rehabilitation (independent variable) on completion of the SMP (dependent variable).
All patients were admitted to a 10-bed rehabilitation unit at a large, urban hospital and were assessed for entry into this study. Of the 114 patients admitted in a 1-year period, 63 met the following criteria: willing to participate in the study, anticipated length of stay greater than 10 days; and mild to moderate communication and/or cognitive deficits as defined by a rating of 2–5 on the FIM™ Instrument (Linacre, Heinemann, Wright, Granger, & Hamilton, 1994) in the areas of comprehension, expression, memory, and/or problem solving. FIM™ ratings were jointly determined by the healthcare team, which included the rehabilitation nurse, speech-language pathologist, occupational therapist, and physical therapist.
Participants were assigned to groups based on their medical diagnosis. The experimental group consisted of 27 stroke patients (16 right hemisphere, 11 left hemisphere), and the comparison group consisted of 36 patients with a diagnosis of general debility resulting from chronic obstructive pulmonary disease, cardiac disease, or above/below the knee amputation. Analysis of variance revealed no significant differences between the groups in age (F = 2.14, p = .13), comprehension (F = .155, p = .70), expression (F = .91, p = .55), memory (F = .12, p = .73), problem solving (F = .003, p = .95), or number of days in the rehabilitation program (F = 1.23, p = .27). See Table 1.
Data Collection Procedures
This project was reviewed and approved by the hospital internal review board, and signed informed consents were obtained from all participants.
All stroke patients were evaluated by the speech-language pathologists, who used the logical memory and paired-associate learning subtests of the Wechsler Memory Scale (Wechsler, 1987); the orientation, thought organization, and reasoning subtests from the Scales of Cognitive Ability in Traumatic Brain Injury (Adamovich & Henderson, 1992); and informal observation of the ability to follow commands, impulsivity, and awareness of deficits.
Self-Medication Program (SMP)
The SMP was developed by the rehabilitation unit’s head certified rehabilitation nurse (CRRN) and was based on the program described by Kelly (1994). To ensure reliable administration of the program, all nurses on the rehabilitation unit attended a 4-hour program orientation, which covered the patients’ roles and responsibilities as well as their own, information to be provided to the patients, and documentation of progress.
The SMP had three levels. At level 1, teaching sheets covering the purpose of medications and corresponding dosages were distributed to the patient and reviewed by the patient’s primary nurse. The nurse then required the patient to identify each medication; state the amount, time, and correct way to take the medicine; discuss the potential side effects of the medication; when to call a physician with problems; and what to do when a dose is omitted. When the patient provided the information without error for a 48-hour period, the patient advanced to level 2. At this level, the patient was required to request the correct medication within 60 minutes of the scheduled time and continue to demonstrate level 1 behaviors. Patients advanced to level 3 when they requested the medication without error for 48 hours. At level 3, the pharmacist dispensed a 72-hour supply of medicine. The nurse assisted the patient in filling a medication tray from the supplied medications, which was then kept in a locked drawer in the patient’s room. The patient was responsible for obtaining and taking the medications at the correct time. Once the patient was at level 3 for at least 24 hours, the pharmacist interviewed the patient to assess his or her knowledge about the medication. At this time, any problems or questions were addressed. The nurse checked each shift to verify that the medications were taken according to schedule. Participants’ charts were reviewed daily by the CRRN. Data were collected on current SMP levels.
The cognitive rehabilitation program for the stroke patients primarily encompassed training in compensatory strategies, supplemented with restorative exercises. Compensatory strategies were individualized for each participant based on test performance. This included strategies to facilitate learning of medications such as condensed written instructions, color coding medicines and labels, graphic illustrations of schedules, and mnemonic devices. Strategy training incorporated task analysis, error-free learning, repetitive practice trials, and regular review of previously learned information (Ehlhard, Sohlberg, & Albin, 2005).
Restorative exercises addressed attention, memory, problem solving, and reasoning and included attention process training (Sohlberg, McLaughlin, Pavese, Heidrich, & Posner, 2000), workbook activities (Tompkins, 1995), and computer-assisted cognitive retraining software (Chen, Thomas, Glueckauf, & Bracy, 1997; Gontkovsky, McDonald, Clark, & Ruwe, 2002). Patients received 30–60 minutes of treatment 5 days a week for the total length of stay.
Descriptive statistics were calculated for the number of days participants remained at each level in the SMP and their level at discharge. See Table 2. A chi-square analysis was completed to determine the difference in success rate (attainment of level 3) between the two groups. Twenty-six of the 27 stroke participants advanced to level 2 after an average of 5.5 days. Of those, 22 advanced to level 3 after an average of 3.7 days and remained in level 3 until discharge. In contrast, 18 of the 36 debility participants advanced to level 2 after an average of 9.4 days. Thirteen of the 18 advanced to level 3 after an average of 5.3 days and remained there until discharge.
A significant difference in the success rate between the stroke and debility groups was evident (X2 = 19.17, p < .001). Eighty-one percent, or 22 of the 27 stroke patients, reached level 3 and were able to manage their medications independently upon discharge. Thirty-six percent, or 13 of the 36 debility patients, completed the SMP. See Table 3 for the number of participants at each SMP level at the time of discharge.
It has previously been reported that patients with cognitive deficits have difficulty succeeding in SMPs (Schepers et al., 2000; Maddigen et al., 2003; Pereles et al., 1996). The purpose of this study was to examine whether stroke patients with mild to moderate cognitive deficits could succeed in an SMP when given interdisciplinary cognitive rehabilitation. In this study, the speech-language pathologist modified and augmented information provided by the primary nurse; developed specific compensatory strategies to facilitate learning and recall of medications; and used pertinent facts about the patient’s medication and schedule as stimuli for general attention, memory, and problem solving tasks.
The stroke patients who received the cognitive rehabilitation approach had a greater success rate in the SMP than the debility group. In addition, they advanced more quickly through the levels compared to the debility group. These findings suggest that individualized instruction based on a patient’s specific cognitive strengths and weaknesses can be beneficial, and that patients with mild to moderate cognitive deficits should not be excluded from SMPs; rather, efforts should be made to compensate for or remediate these deficits so patients may have the chance to become more independent.
There are several factors that could have influenced the success or failure in the program. The nature and course of each patient’s disease may have played a factor in his or her ability to complete the SMP. The stroke group was very homogeneous in terms of medical history, and the onset of their deficits was relatively recent. Therefore, a degree of spontaneous recovery is expected. Whether they would have completed the SMP during their time in the rehabilitation program without the cognitive rehabilitation is unknown. However, given that other studies found that stroke patients on rehabilitation units were unsuccessful, it is likely that participants in the current study would have encountered difficulty without the support provided by the cognitive rehabilitation program. Participants in the debility group demonstrated a wide range of medical problems. Some of the individuals began to demonstrate cognitive deficits during their hospitalization; however, the specific cause of their deficits could not be documented and could have been due to the postsurgery effect of anesthesia or hypoxia. Other patients in the debility group may have experienced gradual decline in cognitive abilities in relation to diabetic, pulmonary, or cardiac disease. Patients without a known cause of cognitive deficits are not traditionally treated by speech-language pathologists; therefore, this group served well as a comparison group for this study and helped to avoid ethical issues encountered by withholding treatment. The finding that cognitive rehabilitation appeared effective with stroke patients lends credence to providing this intervention to other populations with cognitive deficits.
This study has several limitations that must be recognized. First, the sample size was small. However, this is the first study addressing the issue of cognitive rehabilitation and medication management, and data obtained from this study may be used for a power analysis to determine the appropriate sample size needed to provide more reliable and robust results in a future study. Second, subjects were assigned to groups based on their medical diagnosis. Although groups were matched in terms of severity of cognitive deficits, random assignment of a homogeneous group to a treatment or no treatment group would be more ideal. Finally, the cognitive rehabilitation program was not standardized; the programs were individualized to meet the specific needs of each participant. Although this is the recommended method of rehabilitation (Cicerone, Dahlberg, Kalmar, Langenbahn, Malec, & Bergquist, et al., 2000; Ehlhard et al., 2005; Wilson, 1997; Ylvisaker, Hanks, & Johnson-Greene, 2002), it makes it difficult to determine the efficacy of a specific treatment approach. For example, it cannot be determined whether success in the SMP was attributable to the development of compensatory strategies, the restorative exercises, or both. A more systematic and standardized approach is needed to determine which element of the cognitive rehabilitation program provided the most benefit.
Despite the limitations of this study, an interdisciplinary cognitive rehabilitation approach to medication management holds promise. Future studies may also examine the complexity of the medication regime in relation to success, the benefit of a cognitive rehabilitation program for patients with more severe cognitive deficits, and the long-term benefit of training.
The author would like to thank Carol Hart, RN CRRN, for her dedication to development of the SMP and for her assistance in carrying out this project.
About the Author
Mary H. Purdy, PhD CCC-SLP BC-ANCDS, is an associate professor at Southern Connecticut State University, Department of Communication Disorders and a consultant at Hartford Hospital/Eastern Rehabilitation Network, Hartford, Connecticut. Address correspondence to her at 501 Crescent Street, New Haven, CT 06515, or at firstname.lastname@example.org.
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