Motor disability in the setting of oral anticoagulant therapy

Excerpt

Oral anticoagulant therapy (OAT) is a widely applied measure for the prevention of thrombotic events in a broad range of diseases. OAT is chronically administered and, given its narrow therapeutic range, its management requires close monitoring of prothrombin time (PT) and the international normalized ratio (INR) to balance the risk of hemorrhage and thrombosis. Although PT/INR can be assessed by healthcare professionals or by patients themselves [1], individuals on OAT are usually followed at an outpatient center specializing in hematology. Patients on OAT are typically older individuals and may be affected by various diseases and comorbidities which may exhibit debilitating deteriorations in personal status, physical impairment, several forms of motor disability (MD), and limitations in performing activities of daily living (ADL), the latter eventually resulting in the loss of independence. Moreover, limitations in performing daily activities can compromise the patient’s quality of life (QoL) and increase the burden on caregivers. Therefore, the need of hospital visits may be problematic, given the complex burden of frailty and disability afflicting many patients on OAT, above all the elderly and those with multiple comorbidities. In this regard, hematologists and other medical specialists providing OAT will increasingly be faced with problems arising from functional decline and physical deterioration. Although these concerns are observed as common complaints in patients on OAT in daily clinical practice, information regarding its origins, frequency, and management is relatively scarce. To address this issue, we conducted a cross-sectional evaluation of the MD in a group of consecutive OAT patients. MD was assessed with the Barthel index (BI) [2], which has been used in our previous studies on physical status and motor impairment in hematological patients. As in these previous reports [3, 4], in the present study BI was used as the basic ADL ability scale, and was classified as mild (BI > 66%), moderate (BI 33–66%) and severe (BI < 33%). There were 122 patients (73 male); median age was 71 (27–91) years. Disability was present in 37/122 (30%) patients; of the 37 disabled patients, motor impairment was mild in 33 (90%), moderate in 3 (7%) and severe in 1 (3%) patients, respectively. Analysis of BI items (Fig. 1; Table 1) revealed that bladder function and complex activities are the most frequently impaired basic ADL in patients on OAT. Although preliminary and related to a limited series of patients, our data add to the scarce knowledge on disability in the management of OAT and may stimulate further research on this neglected issue. MD is a frequent feature and larger data analyses are likely to provide a better understanding of the disablement process, onset, causes, related risk factors and progression. Meanwhile, for physically impaired patients on chronic OAT, which are only one-third of the total but represent an important management burden if we consider the entire OAT population, we should develop facilitation strategies. In this view, home care management [5], including the at-home use of a portable PT monitor [1] in selected patients, may be suitable options, although these would require a team of trained healthcare professionals and adequate resources. Therefore, a targeted rehabilitative approach to prevent and treat disability may lead to positive effects on both patient’s QoL and caregiver workload.

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