دانلود رایگان مقاله انگلیسی خطر ممانعت از توانبخشی در سکته مغزی در سنین بسیار بالا - الزویر 2018

Abstract

Objective: To investigate whether oldest-old age (≥85 yr) is an independent predictor of exclusion from stroke rehabilitation. Design: Retrospective cohort study. Setting: Stroke Unit (SU) of an Italian tertiary hospital. Participants: 1055 elderly patients (age 65-74 yr, n=230; age, 75-84 yr, n=432; age ≥ 85 yr, n=393), who, between 2009 and 2012, were admitted to SU with acute stroke and evaluated by a multiprofessional team for access to rehabilitation. The study excluded patients for whom rehabilitation was unnecessary or inappropriate. Interventions: Not applicable. Main Outcome Measures: Access to an early mobilization (EM) protocol during SU stay and subsequent access to post-acute rehabilitation after SU discharge. Analyses were adjusted for prestroke and stroke-related characteristics. Results: 32.2% of patients were excluded from EM. Multivariable-adjusted Odds Ratio (OR) of EM exclusion was 1.30 (95% CI: 0.76, 2.21) for age 75-84 yr and 2.07 (95% CI: 1.19, 3.59) for age ≥85 yr compared to age 65-74 yr. Of 656 patients admitted to EM and who, at SU discharge, had 20 not yet fully recovered their prestroke functionally status, 18.4% were excluded from post-acute rehabilitation. For patients able to walk unassisted at SU discharge, probability of exclusion did not change across age groups. For patients unable to walk unassisted at SU discharge, OR of exclusion from post-acute rehabilitation was 3.74 (95% CI: 1.26, 11.13) for age 75-84 yr and 9.15 (95% CI: 24 3.05, 27.46) for age ≥85 yr compared to age 65-74 yr. Conclusion: Oldest-old age is an independent predictor of exclusion from stroke rehabilitation.

Conclusions

This study shows that, among patients admitted to SU with acute stroke, oldest-old age is an independent predictor of exclusion from EM. Moreover, among stroke patients who at SU discharge are unable to walk unassisted, older age per se is associated with a higher probability of not accessing post-acute rehabilitation. Currently, the stroke rehabilitation triage process mainly relies on subjective clinical judgment.20,41,47 A strong argument has been made for the viewpoint that defining formal criteria for access to rehabilitation may either increase stroke costs (by selecting inappropriate patients) or create self-filling prophecies (by excluding appropriate patients). 47,48 However, when oldest-old stroke patients are concerned, lack of explicit guidelines often lead to therapeutic inertia.49 We hypothesize that the current lack of evidence-based recommendations for rehabilitation of oldest-old stroke patients is likely to favor age discrimination for access to rehabilitation interventions.