Dr Lionel Cosin Orthopaedic surgeon Father of orthogeriatric rehabilitation Pioneered early surgical fixation and mobilisation in frail elderly hip fr

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1 The role of the MDT in orthogeriatric rehabilitation Colin McCarthy Consultant Geriatrician Greater Glasgow and Clyde Health Board

2 Dr Lionel Cosin Orthopaedic surgeon Father of orthogeriatric rehabilitation Pioneered early surgical fixation and mobilisation in frail elderly hip fracture patients Founding member of the BGS Founded the first Geriatric Day Hospital

3 Why is a Geriatrician here?

4 National Service Framework for Older People 2001 The care of older people in hospital is complex Ensure early involvement of a consultant in old age medicine or rehabilitation Make use of the available range of professional groups and specialist advice Ensure all staff are properly trained and supported in caring for older people

5 National Service Framework for Older People 2001 maintaining fluid balance pain management pressure sore risk management acute confusion falls and immobility nutritional status and risk management continence risk management cognitive impairment rehabilitation potential depression infection control medicines management social circumstances family and other carers needs how and where to access other specialist services end of life care

6 Rationale for MDT working in hip fracture management Overwhelmingly elderly population Diverse group but high prevalence of co morbidity including cognitive impairment High risk of peri-operative complications, especially delirium, infection and complex fluid management issues Assessment of social support and premorbid functional and cognitive abilities to inform discharge planning Early identification of frail patients for comprehensive geriatric assessment

7 What is MDT rehabilitation? Services provided by a multidisciplinary team with the goal of reducing disability by improving task-oriented behaviour, for example, walking and dressing Multidisciplinary rehabilitation for older people with hip fractures (Review), Cochrane Collaboration 2009 Components of the team vary depending on need but usually include doctors, nurses, physiotherapy, occupational therapy, and social work

8 Stages of MDT rehabilitation Assessment: : identification, analysis and identification of problems Planning: : analysing the problem(s) and setting goals Treatment: : intervention to reduce disability and handicap Evaluation: : check effectiveness of interventions and review (i.e. reassessment) Care: : intervention to alleviate consequences of disability Advice: : coping strategies for patients and carers

9 Models of care 1. Traditional / Usual care all components available, but no formal arrangements for co-ordinated ordinated multidisciplinary teamwork 2. Orthogeriatric care combined care on a shared ward (Hip Fracture Programme) 3. GORU surgical care followed by early postoperative transfer to a separate geriatrician-led rehabilitation ward 4. Early Supported Discharge discharge from the acute trauma ward with a community based rehabilitation programme

10 Multidisciplinary rehabilitation for older people with hip fractures (Review) Cochrane 2009 Intervention - Specialised multidisciplinary rehabilitation supervised by a geriatrician or rehabilitation physician (a medical practitioner with skill and experience in rehabilitation) compared with usual care, for older people with hip fracture, in either an inpatient rehabilitation setting, an ambulatory rehabilitation setting or both Conclusion - While there was a tendency to a better overall result in patients receiving multidisciplinary inpatient rehabilitation, these results were not statistically significant

11 NICE CQ124 (2011) - The management of hip fracture in adults No direct comparisons of GORU v Orthogeriatric care models No evidence of harm from MDT rehabilitation Improvement in functional outcome at 1 year, though this has not been shown to lead to greater success in achieving patients' objective of returning to their original residence Trend toward reduced mortality at discharge, 1, 6 and 12 months, which must reflect an effect in reducing medical and/or surgical complications (problems with diagnosis, definition and ascertainment leave this issue unclear) Reduced hospital length of stay Both Orthogeriatric and GORU proved markedly more cost-effective than usual care

12 Take Home Message Hip fracture patients are elderly and frail with multiple co morbidities Multidisciplinary intervention is good practice and should be based on effective communication between team members Ultimately, these patients likely do best with multidisciplinary input and rehabilitation co-ordinated ordinated by a specialist physician, usually a Geriatrician