Geriatric Rehabilitation: post-acute best care for older trauma patients?

Wilco Achterberg

Professor of Elderly Care Medicine

Dpt of Public Health & primary care, LUMC

Topaz

LEIDEN

@wilcoachterberg

No conflict of interests

2 Leiden GEM 2017

#geriEM

1- Wat is belangrijk bij het herstel van een

89 jarige na een heupfractuur?

2- Wie is belangrijk bij het herstel van een

89 jarige na een heupfractuur?

Mentimeter questions…..

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医院只是医疗中心，养病康复必须到别处

医疗卫生监督: 关心出院后的护理

请叫救护车，让他能在适宜的

环境中醒来

平均住院时间为4.3 天

(2009年)

5

Clin. Ger. Med 8; 8(1) Buchner & Wagner, Preventing frail Health 1992, 1-17

Why and for whom ‘geriatric’ rehabilitation?

Leiden GEM 2017

yes

Hip fracture (20.000)

Stroke (41.000)

Other (…….)

45.000 of these patients receive

geriatric rehabilitation in nursing

homes with multidisiciplinary teams

to restore function and participation

no

- Pelvis fracture

- Contusion

- Large haematoma

- Infection

- …….

Who/what takes care of their

functional recovery?

6

Hospital admission necessary?

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Key-elements geriatric rehabilitation

Triage/case selection in hospital

Multidisciplinary

Individual treatment/rehabilitation plan

Goal setting with the patient!

Therapeutic climate: ‘everything is rehabilitation’

Last part ambulatory!

80% is going home after mean 45 GR days in NH

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[Geïntegreerde multidisciplinaire zorg die gericht is op verwacht herstel van functioneren en participatie bij laag- belastbare ouderen (frail elderly) na een acute aandoening of functionele achteruitgang.] (Werkgroep geriatrische revalidatie Verenso)

Integrated multidisciplinary care Aimed at expected recovery Of function and participation In frail elderly After acute episode or functional decline

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Do we agree on definition?

8

2013: differences in law…

Only after Hospital

admission

Back to

home

Not in

LTC

9

10 Leiden GEM 2017

‘Detour’ policy since 2015

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Acute functional decline

No medical treatment/admission

necessary in hospital

Not able to go back to own home

Needs multidisciplinary rehabilitation

to go home again

Frailty!

Geriatric assessment!

Functional prognosis

Triage/case selection

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LUMC and TOPAZ

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Decision scheme: GR after ER visit

Check in- & exclusioncriteria

Instruments that are part of CGA

Contact with geriatrician

Prepares documentation & transport for transefer (patient file, medication

etc.)

ER nurse

Assesses patient: • learnability • Multimorbidity • Cognition • Motivation

Geriatrician

Deliberations with elderly care physician

Patiënt goes to GR NH

First 15 patients in project ‘from ER to GR’

Fractures 11 2x lower extr 4x upper extr 5x thorax/head

(4 x in combi with other problem)

Bleeding 1

Contusion 1

Luxation 1

Infection 1

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Characteristics

Female 11/15 (73%)

age Gem 79,5

fall 11/15 (73%)

Home care 2/15 (13%)

Informal care giver 4/13 (31%)

Aid before 1/12

comorbidities Mean 7,9 (median 5)

> 5 medications 5/12 (42%)

Rontgen 11/15 (4x CT, 2x echo)

lab 2/14

6-CIT score (0-7) Mean 1,23 (mediaan: 0)

Barthel score (0-20) SEH Mean 13,9 (mediaan: 14)

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After GR (n=15)

To own home 100%

uncomplicated 11/15 (73%)

LOS GR Mean 31 (median: 27)

Barthel index discharge GR (0-20;) Mean 17,7 (= + 4 compared to admission)

Home care after GR 8/13 (62%)

Fysiotherapy after GR 9/13 (69%)

Aid after 11/15 (73%, walker, walking stick etc)

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- After acute loss of function GR is a good option

- No hospital admissions

- Hell of a job on a ED to make this happen, but possible!

Evaluation

Medical treatment in hospital?- Hospital admission

Care dependency? (temporarily) nursing facility

Rehabilitation need? (with geriatric treatment) GR facility

Don’t mix these up!!

My mentimeter

Wie:

1 de patient,

2 de mantelzorger,

3 het team

Wat:

1 snel functioneel oefenen

2 persoonlijke doelstelling patient

3 ketenafspraken

Who:

1 the patient

2 informal care giver

3 the team

What:

1 ASAP functional training

2 personal goal setting by patient

3 ‘care chain deal’

RESTORE 4 STROKE: >70: 63% home, <70: 76%

Having a spouse is a

barrier for receiving

geriatric rehabilitation in

older stroke patients!!

Thank for your attention!

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