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Medications, Comorbidities, and Medical Complications in Stroke Survivors: The CAReS Study
Stroke survivors enter rehabilitation units with many medical comorbidities and often experience significant complications during their stays. The 97 stroke survivors discharged home in this study received prescriptions for a mean of 11.3 medications from 5.4 different drug classifications. There were significant correlations between the number of comorbidities and after stroke complications and the number of different classifications of drugs that were ordered. This article (1) identifies the types of medications prescribed for stroke survivors who are being discharged home from rehabilitation, (2) explores correlations between medication prescriptions and the number of stroke-related comorbidities and medical complications, (3) identifies the cost of medications and the potential effect of medication costs on stroke survivors, and (4) discusses the nurse’s role in preparing stroke survivors and their caregivers for medication use after discharge. Rehabilitation nurses bear the major responsibility for teaching stroke survivors and their caregivers about their discharge medications.
Stroke survivors present unique challenges to rehabilitation nurses because most strokes occur in the context of other serious medical diagnoses, which increase stroke survivors’ propensity for developing medical complications during the rehabilitation process. Unlike many patients seen in rehabilitation units, stroke survivors are more likely to be older and to have other chronic medical conditions. Many stroke survivors are started on new medications, such as antihypertensives or anticoagulants, during hospitalization in an attempt to control risk factors and prevent recurrent strokes. Furthermore, complications of the stroke, such as depression and seizures, may require new medications. Nurses are responsible for administering medications while the stroke survivor is an inpatient and for educating stroke survivors and their caregivers about the proper use of medications after discharge.
Diabetes, hypertension, and congestive heart failure are becoming increasingly common among stroke survivors (Fang & Alderman, 2001); hypertension is the most common risk factor reported among stroke survivors, regardless of stroke type (Williams, Sheppard, Marrufo, Galbis-Reig, & Gaskill, 2003). Other risk factors for stroke, such as coronary artery disease, high cholesterol, and atrial fibrillation, may also be present and require special medications.
Stroke survivors commonly experience medical complications during the rehabilitation stay. Depression, urinary tract infection, and limb pain have been reported as three of the most common complications experienced by stroke survivors (McLean, 2004). The use of medical tubes (tracheostomies, enteral feeding tubes, and indwelling urinary catheters) and associated complications are also increasing in rehabilitation units (Roth & Lovell, 2003). The increasing number of comorbidities and complications illustrate the medically active nature of many rehabilitation units today (Roth, Lovell, Harvey, & Heinemann, 2002).
For most stroke survivors, discharge home is only one more step in a long process of recovery. The availability of family caregivers to help in the continuing recovery process has been shown to be an important predictor of discharge home after a stroke. Married stroke survivors, those living with another person, and survivors with unemployed caregivers had a greater chance of being discharged home than those without available caregivers (Black et al., 1999; Stineman et al., 2001). After discharge, family caregivers assume many healthcare tasks, including the administration and supervision of medications.
Researchers who have contacted stroke survivors and their family caregivers after discharge reported that they were frustrated with the lack of information that they received before discharge and continued to have questions during the first 6 months at home (Bakas et al., 2002; Best, 1994; Clark, 2000). Forster et al. (2001) conducted a systematic Cochrane review to examine strategies for providing information to stroke survivors and their caregivers. They concluded that future work should be directed toward addressing the expressed needs of stroke survivors and their caregivers and identifying appropriate teaching strategies, which can be successfully implemented in clinical practice.
This article (1) identifies the types of medications prescribed for stroke survivors who are being discharged home from rehabilitation, (2) explores correlations between medication prescriptions and the number of stroke-related comorbidities and number of medical complications, (3) identifies the cost of medications and the potential effect on stroke survivors, and (4) discusses the nurse’s role in preparing stroke survivors and their caregivers for medication use after discharge.
The sample for this study was 97 stroke survivors who were at least 50 years of age and who had been discharged home from one of five hospital systems within the Texas Medical Center between November 2001 and December 2003; all stroke survivors in the sample had spousal caregivers. The data presented in this article are a part of CAReS (Committed to Assisting with Recovery after Stroke), an interdisciplinary, intervention study with stroke survivors and their spousal caregivers that was funded for 5 years by the National Institute for Nursing Research. The study was approved by the university institutional review board committee and by the institutional review board committees of the healthcare systems from which patients were recruited.
Demographic data, stroke-related comorbidities, medical complications, and the prescriptions for discharge medications were abstracted from each patient’s chart by trained nurses and occupational therapists. The four-factor Hollinghead’s formula was used to determine socioeconomic status (SES; Hollingshead, 1979). A baccalaureate-prepared nurse interviewed stroke survivors in their homes to verify the discharge medication prescriptions.
Data Management and Analysis
All data, except medications, were collected on specially designed scannable data collection forms using Cardiff Teleform software, version 8.1. The data forms were checked for data completeness before scanning. During the scanning process, the Teleform software interpreted and validated the scanned data. All data forms were stored in a locked cabinet in a locked office with access limited to the data management staff. After all data had been checked for accuracy, they were directly scanned to a Microsoft Access® database stored on a double password protected dedicated computer with no Internet connection. The medications were entered by a registered nurse into a specially designed Access database that allowed the generic and trade names (i.e., brand names) to be entered and the medications to be classified into categories according to purpose, such as antihypertensives and antidepressants. Information on the average wholesale price (AWP) of sample medications was obtained from the Red Book (Economics, 2004). Data were imported into SAS software, version 8.2, where basic and inferential statistics, including frequencies, means, correlations, t tests, and chi-square analyses, were performed. The sums do not always add to 97 because of missing data.
The average age of the participants was 66.2 years (SD = 8.84, range 50–87), and 74 (76.3%) were male. Eighty-two (84.6 %) had at least a high school education, and 43 (44.3%) were non-White. Seventy-six had comprehensive insurance coverage (Medicare with supplement, private insurance, or veterans’ health benefits), but the remaining 21 had limitations to their healthcare coverage with the potential for high out-of-pocket costs.
Stroke survivors experienced an average of 2.38 stroke-related comorbidities (SD = 0.85, range 0–6). The three leading stroke-related comorbidities in this study were hypertension (n = 82, 86.5%); history of cardiac related comorbidities including arrhythmias, faulty heart valves, and coronary artery disease (n = 62, 64.6%); and diabetes (n = 37, 38.5%). On average, patients experienced 3.9 complications (SD = 3.18, range 0–13) with the most common being depression (n = 43, 44.8%).
Stroke survivors were discharged home with an average of 11.3 medications (SD = 4.94, range 3–27) per person from 5.4 different drug classifications (SD = 2.07, range 1–12). The number of medications prescribed was correlated with the number of stroke-related comorbidities (r = 0.214, p = .04). Receiving prescriptions for medications from several different drug classifications was correlated with having more stroke-related comorbidities (r = 0.203, p = .05) and more complications (r = 0.229, p = .03). There were no correlations between the number of medications or the number of drug classifications and age, gender, education, socioeconomic status (SES), or the number of days in rehabilitation.
The most common classifications of medications, with an example of one commonly prescribed medication in each classification, is shown in Table 1. The medication prescriptions were consistent with the stroke-related comorbidities and medical complications identified in the charts. Eighty of the 83 (96.4%) stroke survivors with a diagnosis of hypertension were discharged on antihypertensive medications. Antidiabetic medications were prescribed for 86.5% of those with a diagnosis of diabetes and nine additional stroke survivors who had hyperglycemia. Of the 43 patients with a diagnosis of after stroke depression, 38 (88.4%) were discharged on antidepressant medications. In addition, 23 patients without a recorded diagnosis of depression were discharged with a prescription for an antidepressant; 61 of the 97 stroke survivors (63.5%) were discharged with prescription for antidepressant medications. Other common complications which were reflected in the medication prescriptions were seizures, infections, (especially urinary tract infections), constipation, and pain.
The monthly cost of these medications can be overwhelming for families that do not have medication coverage or those with lower SES. The per dose and monthly AWP of 10 common medications used by stroke survivors with risk factors of diabetes, hypertension, and hyperlipidemia and with medical complications of depression, after stroke central pain, and seizures are shown in Table 2.
Stroke survivors incur significant costs for medications. In the example above, stroke survivors not eligible for discounts, such as those without insurance or stroke survivors on Medicare without supplements, would incur the total monthly cost of approximately $725. In addition, even those with medication coverage may incur out-of-pocket copayment expenses of $200 or more for their medications. After discharge, stroke survivors reported missing utility payments to buy medications, buying less than 30 pills at a time to stretch payments throughout a month, skipping doses to make the pills last longer, getting free samples from their physician’s offices, and going to Mexico to buy medications for reduced cost.
Stroke survivors were discharged home with an average of more than 11 medications from five different drug classifications. The types of medications prescribed were consistent with the comorbidities and complications experienced by the survivors. In this study, 75% of the stroke survivors received prescriptions for Plavix, and 23% received prescriptions for anticoagulants. Although previous studies have reported that Asian/Pacific Islander, Black, and Hispanic participants eligible for anticoagulant therapy received it less often than non-Hispanic White nursing home residents (Christian et al., 2003), this study did not find any association between race and ethnicity, SES, or type of insurance and medication prescriptions.
Likewise, after stroke depression has sometimes been described as underdiagnosed and undertreated. However, in this study, more than 60% of the stroke survivors were discharged with prescriptions for antidepressants. This is consistent with others (Eriksson et al., 2004) who found that only 8.4% of stroke survivors who reported a depressive mood were not on an antidepressant; in this study only 5.3% of those with after stroke depression were sent home without a prescription for an antidepressant medication. Antidepressant medications were the fourth most commonly prescribed medication, preceded only by antihypertensive, antiplatelet, and antihyperlipidemia medications.
Rehabilitation nurses bear the major responsibility for teaching stroke survivors and their caregivers about the medications that they will be taking after discharge home. Yet, very little is written in the literature about this important responsibility. Procedures for preparing stroke survivors and their caregivers for discharge are inconsistent among rehabilitation units. Some send medications home with the stroke survivors, some send prescriptions, and some arrange to have prescriptions mailed to the home. Likewise, some units provide both oral and written information on all medications, some provide a list of medications with no specific written instructions, and some provide no information. Medication discharge instructions, if they occur at all, are frequently left to shortly before discharge. Because of medication costs, inquiries should be made about insurance coverage. If necessary, the nurse should provide information on sources of low-cost medications. If the nurse is not familiar with this information, social workers should be involved in the process. In this study, we did not encounter any stroke survivors or caregivers who were assisted with obtaining medications at reduced cost or no cost, other than free starter samples from doctors’ offices. Several medication issues were identified by nurses in this study who visited the stroke survivors in their homes following discharge. These included medications that had been ordered but were slow in arriving, lack of information about medications that were new, lack of appointments for follow-up laboratory work, failure to discontinue medications that the stroke survivor was previously taking for another chronic disease, lack of transportation to get needed medications, and lack of money to pay for the medications.
At least 48 hours before discharge, the nurses should clarify with the physicians what medications will be sent home with the stroke survivor. If pharmacists are available within the setting, they may also be involved in preparing stroke survivors for discharge. Written instructions should be prepared and reviewed with the stroke survivor and caregiver with special emphasis on medications that are new (e.g., antiseizure medications), those with potential side effects (e.g., antidiabetic medications), those that may have interactions with foods or other drugs (e.g., anticoagulants), and those that need regular follow-up (e.g., antihypertensive medications). Some stroke survivors may not be able to read or may have poor sensory perception or cognitive deficits, so different teaching strategies, including models and pictures, should be used. In addition, a caregiver should be involved in the instruction if the stroke survivor is being discharged home. Before discharge, the nurse should ensure that appointments are made for laboratory work or other special procedures that will be necessary within 1–2 weeks after discharge.
The nurse should determine whether the stroke survivor was admitted with medications for another chronic illness that are not included with the current discharge medications and clarify with the physician whether those medications should be continued. In addition, the nurse should determine whether the stroke survivor has insurance to cover medications or financial resources to pay for either the medications or the insurance copayment. Nurses should work with physicians to simplify the medication regimes that will be required at home. Discussions about how and when the medications should be taken, where they should be stored, and strategies for dispensing and recording them are important topics that are often neglected. Medication discussions may need to occur over several days to ensure that all topics are covered. Nurses or social workers should also provide information on sources of low-cost medications, which may include assistance in applying for Medicaid or Medicare drug discount cards or submitting applications to pharmaceutical companies that are available on www.needymeds.com. Because some of these applications can take several weeks, they are best initiated before discharge to home.
Stroke survivors who are discharged home without understanding the purpose and potential side effects of their medications, without plans for medical follow-up, or without the resources to obtain their medications are at risk for developing excess disability. Rehabilitation nurses play an important role in preparing the stroke survivors and their families to use their medications safely in their home environment.
This work was supported by the National Institutes of Health, National Institute for Nursing Research RO1 NR005316 (Sharon K. Ostwald, PI), and the Isla Carroll Turner Friendship Trust. We wish to thank Franzina Coutinho, MOT, Karen Janssen, BSN, Michelle Peck, BSN, Paul Swank, PhD, and Xiaoling Zhang, MS, for their assistance with this study.
About the Authors
Sharon K. Ostwald, PhD RN FGSA, is a professor and Isla Carroll Turner Chair in gerontological nursing at the Center on Aging, University of Texas School of Nursing, Houston, TX. Address correspondence to her at UTSON-H Center on Aging, 6901 Bertner, Room 614, Houston, TX 77030, or to Sharon.K.Ostwald@uth.tmc.edu.
Joan Wasserman, MBA DrPH RN, is an assistant professor of nursing at the Center on Aging, University of Texas School of Nursing.
Sally Davis, MSN RN, is an advanced practice nurse at the Center on Aging, University of Texas School of Nursing.
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