The ageing of the population: implications for multidisciplinary care in hospital

Implementing a multidisciplinary rapid geriatric observation unit for non-critical older patients referred to hospital: observational study on real-world data

BACKGROUND

Geriatric rapid observation units may represent an alternative to hospitalization in older patients with non-critical acute illness.

AIMS

To describe the characteristics and outcomes of patients admitted to a geriatric observation unit called URGe (Unità Geriatrica Rapida), implemented in an Italian hospital and characterized by multidisciplinary medical staff with geriatric expertise, fast-track access to diagnostic resources, regular use of point-of-care ultrasound and predicted length of stay (LOS) < 72 h.

METHODS

The medical records of patients admitted to URGe during a 3-month period (452 subjects, 247 F and 205 M, median age 82 years, IQR 77-87) were retrospectively examined. The primary study endpoint was transferral from URGe to regular wards. Baseline covariates included demographics, comprehensive geriatric assessment, acute illnesses, comorbidities, vital signs and routine laboratory tests.

RESULTS

Despite elevated burden of multimorbidity (median number of chronic diseases 4, IQR 2-5) and frailty (median Rockwood Clinical Frailty Scale score 4, IQR 3-6), only 137 patients (30.3%) required transferral from URGe to regular wards. The main factors positively associated with this outcome were Rockwood score, fever, cancer and red cell distribution width (P < 0.05 on multivariate logistic regression model). The rate of complications (mortality, delirium, and falls) during URGe stay was low (0.5%, 7% and 2%, respectively). Overall duration of hospital stay was lower than that of a group of historical controls matched by age, sex, main diagnosis, multimorbidity and frailty.

CONCLUSIONS

The URGe model of acute geriatric care is feasible, safe and has the potential of reducing unnecessary hospitalizations of older patients.

Graft factors as determinants of postoperative delirium after liver transplantation

Post-operative delirium (POD) is a frequent complication after surgery, occurring in 15-20% of patients. POD is associated with a higher complications rate and mortality. Literature on POD after liver transplantation (LT) is limited, with the few available studies reporting an incidence of 10-47%. The aim of this study was analyzing pattern, risk factors and clinical impact of POD after LT. Data on donor and recipient characteristics, postoperative course and POD of consecutive adult LT recipients from March 2016 to May 2018 were prospectively collected and retrospectively analyzed. Risk factors for POD were analyzed using univariable logistic regression and Lasso regression. Kaplan-Meier method was used for survival analysis. 309 patients underwent LT during study period; 3 were excluded due to perioperative death. Incidence of POD was 13.4% (n = 41). The median day of onset was 5th (IQR [4-7]) with a median duration of 4 days (IQR [3-7]). Several risk factors, related to the severity of liver disease and graft characteristics, were identified. Graft macrovesicular steatosis was the only factor independently associated with POD at multivariable analysis (OR 1.27, CI 1.09-1.51, p = 0.003). POD was associated with a higher rate of severe postoperative complications and longer intensive care unit and hospital stay, but did not significantly impact on patient and graft survival. Incidence of POD after LT is comparable to that observed after general surgery and graft factors are strongly associated with its onset. These results help identifying a subset of patients to be considered for preventive interventions.

"How do Pilates Trained Physiotherapists utilize and value Pilates Exercise for MSK conditions? A Qualitative Study"

BACKGROUND

Pilates is a popular exercise therapy approach offering numerous benefits, including muscular strength, flexibility, control, and core stability. Pilates has been widely utilized in the prevention and rehabilitation of a variety of musculoskeletal disorders.

OBJECTIVES

The aim of this study was to explore the experiences and opinions of Pilates trained NHS and private practice physiotherapists in the UK, regarding the perceived benefits, risks, delivery and rationale for this exercise method.

METHODS

This qualitative study used a self-designed electronic survey to retrieve the views of 30 physiotherapists, who had undertaken formal Pilates Instruction training, recruited by a purposive and snowball sampling method. Questions were either multiple choice or open-ended, examined via thematic analysis.

RESULTS

Physiotherapists identified the most important benefits of Pilates as reduction in fear-avoidance, improving bodily awareness and increasing muscular strength. Exercises that promote general movement were highlighted as being particularly useful, with a majority recommending daily practice for optimum benefit. Participants recognized lack of core strength as a key indicator, whereas others criticized excessive focus on this principle.

CONCLUSIONS

Physiotherapists identified a range of inter-linked benefits and recognized that Pilates is hugely modifiable. Individualizing exercises can further encourage participation and negate the restriction of some health conditions. NHS and Private Practice Therapists utilize Pilates in a similar way, although rationales for its use may differ, as the justification for Pilates exercise may be evolving. Pilates appears a valuable methodology in the NHS, which can help patients engage with activity.

Postoperative Delirium as a Target for Surgical Quality Improvement

OBJECTIVE

To explore hospital-level variation in postoperative delirium using a multi-institutional data source.

BACKGROUND

Postoperative delirium is closely related to serious morbidity, disability, and death in older adults. Yet, surgeons and hospitals rarely measure delirium rates, which limits quality improvement efforts.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Geriatric Surgery Pilot (2014 to 2015) collects geriatric-specific variables, including postoperative delirium using a standardized definition. Hierarchical logistic regression models, adjusted for case mix [Current Procedural Terminology (CPT) code] and patient risk factors, yielded risk-adjusted and smoothed odds ratios (ORs) for hospital performance. Model performance was assessed with Hosmer-Lemeshow (HL) statistic and c-statistics, and compared across surgical specialties.

RESULTS

Twenty thousand two hundred twelve older adults (≥65 years) underwent inpatient operations at 30 hospitals. Postoperative delirium occurred in 2427 patients (12.0%) with variation across specialties, from 4.7% in gynecology to 13.7% in cardiothoracic surgery. Hierarchical modeling with 20 risk factors (HL = 9.423, P = 0.31; c-statistic 0.86) identified 13 hospitals as statistical outliers (5 good, 8 poor performers). Per hospital, the median risk-adjusted delirium rate was 10.4% (range 3.2% to 27.5%). Operation-specific risk and preoperative cognitive impairment (OR 2.9, 95% confidence interval 2.5-3.5) were the strongest predictors. The model performed well across surgical specialties (orthopedic, general surgery, and vascular surgery).

CONCLUSION

Rates of postoperative delirium varied 8.5-fold across hospitals, and can feasibly be measured in surgical quality datasets. The model performed well with 10 to 12 variables and demonstrated applicability across surgical specialties. Such efforts are critical to better tailor quality improvement to older surgical patients.

Interventions for preventing delirium in hospitalised non-ICU patients

BACKGROUND

Delirium is a common mental disorder, which is distressing and has serious adverse outcomes in hospitalised patients. Prevention of delirium is desirable from the perspective of patients and carers, and healthcare providers. It is currently unclear, however, whether interventions for preventing delirium are effective.

OBJECTIVES

To assess the effectiveness of interventions for preventing delirium in hospitalised non-Intensive Care Unit (ICU) patients.

SEARCH METHODS

We searched ALOIS - the Cochrane Dementia and Cognitive Improvement Group's Specialized Register on 4 December 2015 for all randomised studies on preventing delirium. We also searched MEDLINE (Ovid SP), EMBASE (Ovid SP), PsycINFO (Ovid SP), Central (The Cochrane Library), CINAHL (EBSCOhost), LILACS (BIREME), Web of Science core collection (ISI Web of Science), ClinicalTrials.gov and the WHO meta register of trials, ICTRP.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of single and multi- component non-pharmacological and pharmacological interventions for preventing delirium in hospitalised non-ICU patients.

DATA COLLECTION AND ANALYSIS

Two review authors examined titles and abstracts of citations identified by the search for eligibility and extracted data independently, with any disagreements settled by consensus. The primary outcome was incidence of delirium; secondary outcomes included duration and severity of delirium, institutional care at discharge, quality of life and healthcare costs. We used risk ratios (RRs) as measures of treatment effect for dichotomous outcomes; and between group mean differences and standard deviations for continuous outcomes.

MAIN RESULTS

We included 39 trials that recruited 16,082 participants, assessing 22 different interventions or comparisons. Fourteen trials were placebo-controlled, 15 evaluated a delirium prevention intervention against usual care, and 10 compared two different interventions. Thirty-two studies were conducted in patients undergoing surgery, the majority in orthopaedic settings. Seven studies were conducted in general medical or geriatric medicine settings.We found multi-component interventions reduced the incidence of delirium compared to usual care (RR 0.69, 95% CI 0.59 to 0.81; seven studies; 1950 participants; moderate-quality evidence). Effect sizes were similar in medical (RR 0.63, 95% CI 0.43 to 0.92; four studies; 1365 participants) and surgical settings (RR 0.71, 95% CI 0.59 to 0.85; three studies; 585 participants). In the subgroup of patients with pre-existing dementia, the effect of multi-component interventions remains uncertain (RR 0.90, 95% CI 0.59 to 1.36; one study, 50 participants; low-quality evidence).There is no clear evidence that cholinesterase inhibitors are effective in preventing delirium compared to placebo (RR 0.68, 95% CI, 0.17 to 2.62; two studies, 113 participants; very low-quality evidence).Three trials provide no clear evidence of an effect of antipsychotic medications as a group on the incidence of delirium (RR 0.73, 95% CI, 0.33 to 1.59; 916 participants; very low-quality evidence). In a pre-planned subgroup analysis there was no evidence for effectiveness of a typical antipsychotic (haloperidol) (RR 1.05, 95% CI 0.69 to 1.60; two studies; 516 participants, low-quality evidence). However, delirium incidence was lower (RR 0.36, 95% CI 0.24 to 0.52; one study; 400 participants, moderate-quality evidence) for patients treated with an atypical antipsychotic (olanzapine) compared to placebo (moderate-quality evidence).There is no clear evidence that melatonin or melatonin agonists reduce delirium incidence compared to placebo (RR 0.41, 95% CI 0.09 to 1.89; three studies, 529 participants; low-quality evidence).There is moderate-quality evidence that Bispectral Index (BIS)-guided anaesthesia reduces the incidence of delirium compared to BIS-blinded anaesthesia or clinical judgement (RR 0.71, 95% CI 0.60 to 0.85; two studies; 2057 participants).It is not possible to generate robust evidence statements for a range of additional pharmacological and anaesthetic interventions due to small numbers of trials, of variable methodological quality.

AUTHORS' CONCLUSIONS

There is strong evidence supporting multi-component interventions to prevent delirium in hospitalised patients. There is no clear evidence that cholinesterase inhibitors, antipsychotic medication or melatonin reduce the incidence of delirium. Using the Bispectral Index to monitor and control depth of anaesthesia reduces the incidence of postoperative delirium. The role of drugs and other anaesthetic techniques to prevent delirium remains uncertain.

Geriatric medicine and geriatricians in the UK. How they relate to acute and general internal medicine and what the future might hold?

The Royal College of Physicians and its Future Hospitals Commission has a renewed focus on general internal medicine. But in 2015, most is in effect either acute medicine or geriatric medicine. Acute physicians and 'organ specialists' looking after inpatients on specialty wards or at the acute hospital 'front door' will need sufficient skills in geriatric medicine, rehabilitation, discharge planning and palliative care, as frailty, dementia and complex comorbidities may complicate the care of older patients with predominant speciality-defining complaints. In an era where we are urged to focus on patient-centred care, patients' preference for continuity and 'whole-stay', consultants must be recognised and respected. Ideally, this will require increasing numbers of geriatricians and acute physicians, more age attuned training for all; a shift in values and status. This should be backed by adequate capacity and rapid access to social and intermediate care services outside hospital, as well as adequate multidisciplinary staff and skills within the acute hospital to ensure that older patients' needs beyond the immediate complaints are not neglected. Meanwhile, geriatric medicine itself has diversified into specialised, community and interface roles, aligned with the integration agenda, and continues to contribute substantially to acute, general and stroke medicine. These developments are described here.

[German version of the de Morton mobility index. First clinical results from the process of the cross-cultural adaptation]

BACKGROUND

The English version of the de Morton Mobility Index (DEMMI) enables allied health professions in an inpatient setting to assess the mobility of geriatric patients in a reliable, valid, easy and fast way, without showing any floor or ceiling effects. The aim of this study was the DEMMI's cross-cultural adaption into German language with further analysis of some of its psychometric properties based on this process.

MATERIAL AND METHODS

Translation was done in a multistage procedure following international recommendations. Within clinical pilot testing the DEMMI was routinely applied over a period of 3 weeks in a geriatric hospital. User experiences were evaluated in a qualitative way and DEMMI test results were analyzed with the focus on practicability and responsiveness.

RESULTS

A German DEMMI version has been translated and performed with 133 patients. The test takes approximately 10 min to administer, is save and easy to use and does not show any floor or ceiling effects. The DEMMI is valid for the whole mobility spectrum, that is why mobility changes can be realized sufficiently in contrast to the Timed Up And Go Test.

CONCLUSION

The DEMMI is already applicable in the German-speaking world. However, further research on its validity and reproducibility are desirable.

Prevention of delirium (POD) for older people in hospital: study protocol for a randomised controlled feasibility trial

Background

Delirium is the most frequent complication among older people following hospitalisation. Delirium may be prevented in about one-third of patients using a multicomponent intervention. However, in the United Kingdom, the National Health Service has no routine delirium prevention care systems. We have developed the Prevention of Delirium Programme, a multicomponent delirium prevention intervention and implementation process. We have successfully carried out a pilot study to test the feasibility and acceptability of implementation of the programme. We are now undertaking preliminary testing of the programme.

Methods/Design

The Prevention of Delirium Study is a multicentre, cluster randomised feasibility study designed to explore the potential effectiveness and cost-effectiveness of the Prevention of Delirium Programme. Sixteen elderly care medicine and orthopaedic/trauma wards in eight National Health Service acute hospitals will be randomised to receive the Prevention of Delirium Programme or usual care. Patients will be eligible for the trial if they have been admitted to a participating ward and are aged 65 years or over. The primary objectives of the study are to provide a preliminary estimate of the effectiveness of the Prevention of Delirium Programme as measured by the incidence of new onset delirium, assess the variability of the incidence of new-onset delirium, estimate the intracluster correlation coefficient and likely cluster size, assess barriers to the delivery of the Prevention of Delirium Programme system of care, assess compliance with the Prevention of Delirium Programme system of care, estimate recruitment and follow-up rates, assess the degree of contamination due to between-ward staff movements, and investigate differences in financial costs and benefits between the Prevention of Delirium Programme system of care and standard practice. Secondary objectives are to investigate differences in the number, severity and length of delirium episodes (including persistent delirium); length of stay in hospital; in-hospital mortality; destination at discharge; health-related quality of life and health resource use; physical and social independence; anxiety and depression; and patient experience.

Discussion

This feasibility study will be used to gather data to inform the design of a future definitive randomised controlled trial.

Trial registration

ISRCTN01187372. Registered 13 March 2014.

Effective strategy for improving health care outcomes: Multidisciplinary care in cerebral infarction patients

Multidisciplinary teams provide effective patient treatment strategies. South Korea expanded its health program recently to include multidisciplinary treatment. This study characterized the relationship between multidisciplinary care and mortality within 30 days after hospitalization in cerebral infarction patients. We used the National Health Insurance claim data (n = 63,895) from 120 hospitals during 2010-2013 to analyze readmission within 30 days after hospitalization for cerebral infarction. We performed χ(2) tests, analysis of variance and multilevel modeling to investigate the associations between multidisciplinary care and death within 30 days after hospitalization for stroke. Deaths within 30 days of hospitalization due to cerebral infarction was 3.0% (n = 1898/63,895). Multidisciplinary care was associated with lower risk of death within 30 days in inpatients with cerebral infarction (odds ratio: 0.84, 95% confidence interval: 0.72-0.99). Patients treated by a greater number of specialists had lower risk of death within 30 days of hospitalization. Additional analyses showed that such associations varied by the combination of specialists (i.e., neurologist and neurosurgeon). In conclusion, death rates within 30 days of hospitalization for cerebral infarction were lower in hospitals with multidisciplinary care. Our findings certainly suggest that a high number of both neurosurgeon and neurologist is not always an effective alternative in managing stroke inpatients, and emphasize the importance of an optimal combination in the same number of hospital staffing.

[University studies plan in geriatric medicine developed using a modified Delphi technique]

INTRODUCTION

The increase in the number of frail elderly people has led to the necessity that all doctors of the future acquire sufficient knowledge on human ageing and the skills in the management of the patient of advanced age, as well as the diseases associated with ageing. Few countries offer geriatric medicine within undergraduate training. The purpose of the present project was to obtain a consensus between European geriatricians on the minimum requirements that medical students must achieve at the end of their university degree course.

MATERIAL AND METHODS

A modified Delphi process was used. Firstly, experts in education and geriatrics proposed a set of learning objectives based on a review of the literature. Three Delphi rounds were then performed, in which a panel of 49 experts representing 29 countries affiliated to the European Union of Medical Specialists took part. This enabled them to reach a consensus on a definitive study plan.

RESULTS

The number of disagreements after the Delphi rounds 1 and 2 were 81 and 53, respectively. Full agreement was reached after the third round. The definitive study plan consisted of detailed objectives grouped under 10 general training objectives.

CONCLUSIONS

A consensus has been reached between European geriatricians that sets specific training objectives for medical students. Great efforts will be required for the introduction of these requirements, given the variability there is in the quality of teaching in geriatrics. This study plan is a first step in helping to improve geriatrics teaching in faculties of medicine, and will also serve as a basis to make advances in the training in post-graduate geriatrics throughout Europe.

The concept of frailty in geriatric chronic kidney disease (CKD) patients

Frailty, which is a geriatric syndrome characterized by weakness, impaired mobility, balance, and minimal reserve, is highly prevalent in the renal population. While distinct from disability and comorbidity, some of the simplest and most clinically useful scales incorporate both the burden of medical symptoms and the effect on functional independence into the evaluation of frailty. In the renal population, the frailty phenotype has been shown to correlate with important outcomes such as hospitalization and survival. Further work is required to establish if the presence of, and the treatments used for renal disease, promote the sick role and decreased participation in exercise with overestimation of frailty or if the frailty phenotype identifies people who may benefit from rehabilitation and other interventions.

[Situation of acute inpatient geriatric patients. A retrospective analysis of health care processes of geriatric and non-geriatric patients with acute myocardial infarction]

BACKGROUND

Although cardiovascular diseases belong to the most frequent causes of inpatient treatment of older people the specific characteristics of geriatric patients in the acute care unit still receive marginal attention. The aim of this study was the descriptive representation of clinical health care processes of geriatric and non-geriatric patients with acute myocardial infarction.

PATIENTS AND METHODS

Using a retrospective document analysis 83 medical patient records were examined with regard to nursing, therapeutic as well as medical measures and social counseling. The classification in geriatric and non-geriatric patients was based on a predefined list of criteria.

RESULTS

In the study a total of 48 geriatric and 35 non-geriatric patients could be identified. There was a comprehensive need for support of nursing and therapeutic care, a high frequency of complications and a long length of stay as well as specifics concerning the place of discharge in geriatric patients.

CONCLUSIONS

Complex problems and special care needs of geriatric patients with acute myocardial infarction were shown. This vulnerable group of patients should be given more attention in acute care. Further investigations with a prospective character are necessary in order to detect the specific needs of geriatric patients in acute care.

European undergraduate curriculum in geriatric medicine developed using an international modified Delphi technique

Introduction: the rise in the number of older, frail adults necessitates that future doctors are adequately trained in the skills of geriatric medicine. Few countries have dedicated curricula in geriatric medicine at the undergraduate level. The aim of this project was to develop a consensus among geriatricians on a curriculum with the minimal requirements that a medical student should achieve by the end of medical school.

Methods: a modified Delphi process was used. First, educational experts and geriatricians proposed a set of learning objectives based on a literature review. Second, three Delphi rounds involving a panel with 49 experts representing 29 countries affiliated to the European Union of Medical Specialists (UEMS) was used to gain consensus for a final curriculum.

Results: the number of disagreements following Delphi Rounds 1 and 2 were 81 and 53, respectively. Complete agreement was reached following the third round. The final curriculum consisted of detailed objectives grouped under 10 overarching learning outcomes.

Discussion: a consensus on the minimum requirements of geriatric learning objectives for medical students has been agreed by European geriatricians. Major efforts will be needed to implement these requirements, given the large variation in the quality of geriatric teaching in medical schools. This curriculum is a first step to help improve teaching of geriatrics in medical schools, and will also serve as a basis for advancing postgraduate training in geriatrics across Europe.

Ageing in the European Union

The ageing of European populations presents health, long-term care, and welfare systems with new challenges. Although reports of ageing as a fundamental threat to the welfare state seem exaggerated, societies have to embrace various policy options to improve the robustness of health, long-term care, and welfare systems in Europe and to help people to stay healthy and active in old age. These policy options include prevention and health promotion, better self-care, increased coordination of care, improved management of hospital admissions and discharges, improved systems of long-term care, and new work and pension arrangements. Ageing of the health workforce is another challenge, and policies will need to be pursued that meet the particular needs of older workers (ie, those aged 50 years or older) while recruiting young practitioners.

Frailty in older inpatients: what physicians need to know

Physicians involved in the care of medical inpatients, irrespective of their sub-specialty area, will be responsible for the management of a significant number of older adults with complex care needs and multiple co-morbidities. These patients are vulnerable to poor outcomes (including falls, institutionalization and death)--a vulnerability often linked with the term 'frail' or 'frailty'. Frailty is associated with advanced chronological age and chronic disease but is a separate construct. The measurement of frailty has received significant attention in recent geriatric medicine literature, with various models proposed to predict the risk of poor outcomes. Here, we briefly review different approaches to the definition of frailty, focusing on the conceptualization of frailty as the failure of a complex system. We explore how falls, a common cause of morbidity and mortality in older patient groups, may be a manifestation of increasing frailty and argue that falls services should avoid the practice of pursuing a single-organ cause when there are likely to be several contributing factors at play. We also consider the impact of frailty on medication prescribing and discuss how individualized prescribing could reduce the risk of adverse drug reactions in at-risk older inpatients. While it can be frustrating for physicians to manage patients who do not fit well into disease-based diagnostic and management algorithms, understanding frailty has the potential to improve the clinical care of vulnerable older people in the hospital setting.

Preventing falls and fall-related injuries in hospitals

Falls are a widespread concern in hospitals settings, with whole hospital rates of between 3 and 5 falls per 1000 bed-days representing around a million inpatient falls occurring in the United States each year. Between 1% and 3% of falls in hospitals result in fracture, but even minor injuries can cause distress and delay rehabilitation. Risk factors most consistently found in the inpatient population include a history of falling, muscle weakness, agitation and confusion, urinary incontinence or frequency, sedative medication, and postural hypotension. Based on systematic reviews, recent research, and clinical and ethical considerations, the most appropriate approach to fall prevention in the hospital environment includes multifactorial interventions with multiprofessional input. There is also some evidence that delirium avoidance programs, reducing sedative and hypnotic medication, in-depth patient education, and sustained exercise programs may reduce falls as single interventions. There is no convincing evidence that hip protectors, movement alarms, or low-low beds reduce falls or injury in the hospital setting. International approaches to developing and maintaining a fall prevention program suggest that commitment of management and a range of clinical and support staff is crucial to success.

The geriatric patient: use of acute geriatrics units in the emergency care of elderly patients in France

We studied the factors influencing the choice of admission to Geriatrics units, instead of other acute hospital units after an emergency visit. We report the results from a cohort of 1283 randomly selected patients aged >75 years hospitalized in emergency and representative of the French University hospital system. All patients underwent geriatric assessment. Baseline characteristics of patients admitted to Geriatrics and other units were compared. A center effect influencing the use of Geriatrics units during emergencies was also investigated. Admission to a Geriatrics unit during the acute care episode occurred in 499 cases (40.3%). By multivariate analysis, 4 factors were related to admission to a Geriatrics unit: cognitive disorder: odds ratio (OR)=1.79 (1.38-2.32) (95% confidence interval=95% CI); "failure to thrive" syndrome OR=1.54 (1.01-2.35), depression: OR=1.42 (1.12-1.83) or loss of Activities of Daily Living (ADL): OR=1.35 (1.04-1.75). The emergency volume of the hospital was inversely related to the use of Geriatrics units, with high variation that could be explained by other unstudied factors. In the French University Emergency Healthcare system, the "geriatrics patient" is defined by the existence of cognitive disorder, psychological symptoms or installed loss of autonomy. Nevertheless, considerable nation-wide variation was observed underlining the need to clarify and reinforce this discipline in the emergency healthcare system.

Multidisciplinary care needs in an Australian tertiary teaching hospital

Background.The ageing of the Australian population is placing increasing demand on the nation’s healthcare system. This study set out to describe the level of need for multidisciplinary care in an Australian tertiary hospital setting. Methods.A cross-sectional audit by case note review of all patients on acute medical and surgical wards in an Australian tertiary hospital. The primary outcome was an identified need for multidisciplinary assessment and intervention. Results.A total of 60% of the 295 inpatients audited required multidisciplinary care. Of those who were admitted to geriatric and rehabilitation units, 84% required multidisciplinary care. Patients in acute medical and surgical units also had substantial multidisciplinary care needs. Age was a significant influence with 79% of those aged 86 and above having multidisciplinary care needs, whilst only 38% of those aged 55 or less required multidisciplinary care. Difficulties with mobility, need for assistance with self-care, and continence problems were associated with higher requirement for multidisciplinary care. Conclusions.In the hospital population, significant multidisciplinary care needs exist. These needs are not limited to inpatients that are elderly or admitted to geriatric or rehabilitation units. This has implications for planning, funding, provision of health care resources, and training of medical and allied health staff. What is known about the topic?Multidisciplinary care is the collaboration of health care staff from a variety of disciplines. This approach has been attributed to reductions in mortality and the duration of length of stay in hospital. Multidisciplinary care is widely applied to older patients and those requiring rehabilitation. However, multidisciplinary care is less frequently adopted in other areas, suggesting that some patients requiring this approach may not receive it. What does this paper add?The findings of this study demonstrate that the need for multidisciplinary care extends beyond aged care and rehabilitation patients. Although the majority of aged care and rehabilitation patients required multidisciplinary care, a significant number of patients in medical and surgical units also needed this approach. What are the implications for practitioners?A need exists for a multidisciplinary approach to be utilised more widely in the hospital setting. Collaboration between allied health and medical staff may require consideration in the allocation of resources for patient care. This also has implications for the training of medical and allied health staff both now and in the future.

Review: Toward Realizing the Potential of Diversity in Composition of Interprofessional Health Care Teams

Interprofessional approaches to health and social care have been linked to improved planning and policy development, more clinically effective services, and enhanced problem solving; however, there is evidence that professionals tend to operate in uniprofessional silos and that attempts to share knowledge across professional borders are often unsuccessful.

Systematic approaches to the prevention and management of patients with delirium

Delirium is a common complication of acute illness in older people. Earlier and more reliable detection could be achieved by greater routine cognitive testing in older people. Research evidence suggests that episodes of delirium and duration of delirium could be reduced by about one third if systems of care that prioritized delirium risk factor amelioration were comprehensively adopted. Specialist delirium units have a place in leading and disseminating best practices. Health service regulators should consider monitoring delirium as an adverse health care outcome.

A comprehensive evaluation of elderly people discharged from an Emergency Department

Elderly people make extensive use of the Emergency Department (ED). After discharge from the ED, these patients are at high risk of short-term adverse outcomes such as functional decline, readmission to the ED, hospitalization and death. We investigated whether a comprehensive geriatric evaluation (CGE) and follow-up of the elderly discharged from the ED can provide them with better diagnosis and treatment, and thus reduce adverse outcomes. Out of 423 elderly patients over 75 years of age discharged from an ED we evaluated 222 of them. The patients were evaluated and treated, based on testing for physical, functional, cognitive and emotional status. A comparison was made between scale scores at baseline and 3 months later. We observed a significant improvement in physical and emotional status in all the studied patients, a significant improvement in behavioural status in the elderly patients with cognitive dysfunction, and a reduction of distress in the caregivers of the elderly patients with cognitive dysfunction and behavioural disturbances. We also found that the rate of ED readmission or hospitalization was lower than in the 3 months preceding the CGE. The experience of older patients with the ED system can be greatly improved if their complex needs are given due attention by developing interdisciplinary programs between emergency physicians, geriatricians, and primary care physicians.

Incidence, preventability and consequences of adverse events in older people: results of a retrospective case-note review

OBJECTIVES

to estimate the extent, preventability and consequences of adverse clinical events in elderly and non-elderly patients.

DESIGN

a two-stage structured, retrospective, patient case-note review.

SETTING

a large NHS hospital in England.

POPULATION

a random sample of 1,006 non-psychiatric patients.

MAIN OUTCOME MEASURES

proportion of patients with adverse events, the proportion of preventable adverse events and the types and consequences of adverse events in patients >or=75 and under 75 years old.

RESULTS

forty five [13.5%; 95% confidence interval (CI) 10-17] of 332 patients >or=75 years and 42 (6.2%; 95% CI 4-8) of 674 patients <75 years had at least one adverse event. There was a significantly raised risk of experiencing an adverse event with increasing age [odds ratio (OR) = 1.03 adverse events per year of life, P < 0.001]. There was no statistically significant difference in preventability of adverse events and also in experiencing disability or death as a result of an adverse event by age after adjustment for potential confounders.

CONCLUSION

adverse events are significantly more common in non-psychiatric elderly inpatients than younger patients. There is little evidence that adverse events in older patients are more preventable and lead to disability or death more frequently.

Preventing falls and falls-injuries in hospitals and long-term care facilities

Falls are predominantly a problem of older people. In the UK, people over 65 currently account for around 60% of admissions and 70% of bed days in hospitals. There are approximately half a million older people in long-term care settings – many with frailty and multiple long-term conditions. The proportion of the population over 65 years is predicted to rise 25% by 2025, and that over 80 by 50%, with a similar increase in those with dependence for two or more activities of daily living. Despite policies to drive care to the community, it is likely that the proportion of older people in hospitals and care homes will therefore increase. Accidental falls are the commonest reported patient/resident safety incidents. Similar demographic trends can be seen in all developed nations, so that the growing problem of fall prevention in institutions is a global challenge. There has been far more focus in falls-prevention research on older people in ‘community’ settings, but falls are a pressing issue for hospitals and care homes, and a threat to the safety of patients and residents, even if a relatively small percentage of the population is in those settings at any one time.