Geriatrics and Gerontology International 2003;

3:

69–72

69

Blackwell Science, LtdOxford, UKGGIGeriatrics and Gerontology International1444-15862003 Blackwell Science Asia Pty LtdJune 2003326972Review Article

Multidisciplinary team approachM Tanaka

Accepted for publication 13 March 2003.

Correspondence: Makoto Tanaka, MD, Department of Social Service Kyoto University Hospital, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto 606–8507, Japan. Email: makoto@kuhp.kyoto-u.ac.jp

REVIEW ARTICLE

Multidisciplinary team approach for elderly patients

Makoto Tanaka

Department of Social Service Kyoto University Hospital

The multidisciplinary team approach plays an increasingly important role in the manage-ment and care of elderly patients, providing support to patients and families and helpingthem adapt to illness and treatment plans – it offers psychosocial counseling, patient andfamily education, discharge planning and post hospital care planning. Multidisciplinaryteam assessment and intervention strategies are also essential in preventing injuries suchas falls and delirium as well as in end of life care. Moreover, teaching hospitals are expectedto provide team training for medical, nursing and social work students to promote earlyexposure to interdisciplinary teamwork.

Keywords:

interdisciplinary team training, medical social service, multidisciplinary teamapproach.

Introduction

The first memory clinic in Japan was opened at ShigaMedical Center in 1990. At that clinic, the small teamconsisted of two physicians, two nurses, a clinical psy-chologist and a social worker who provided comprehen-sive assessment and care of patients with dementia.They organized family caregivers to provide family sup-port and education programs. They also established amedical network with local health care professionals tosupport community-dwelling seniors with dementia.The successful outcome of their team approach had animpact in the field of dementia care in Japan.

It is now widely recognized that multidisciplinaryteam care plays a critical role in today’s medical practice.The multidisciplinary team approach was first intro-duced into medical settings in 1905, when the firstmedical social service department was established atMassachusetts General Hospital (MGH). Ida Cannon,later named Chief of the MGH Social Service Depart-ment, created the field of medical social work, con-vinced that examining the link between illness and thesocial conditions of the patient was critical for effectivemedical practice. Under her influence, social service

departments were introduced into many other hospitalsin the USA. She stated: ‘There should be within thehospital, someone definitely assigned to represent thepatient’s point of view’. Her principles still representcore values for today’s multidisciplinary teamapproach.

1,2

At present, social service departments at hospitalsprovide various services for inpatients and outpatientsas well as their families and caregivers. In this paper,current issues are reviewed and discussed concerningthe role of the multidisciplinary team approach at hos-pitals as well as in the community.

Interdisciplinary team care

It has been widely recognized that physician, nurse andsocial worker collaboration is indispensable for effectivemedical care. Clinical studies have shown benefits ofinterdisciplinary team care in both inpatient and outpa-tient management. Cohen

et al

. conducted a controlledtrial to assess the effects of inpatient and outpatientgeriatric evaluation and management on survival andfunctional status. The intervention teams, each consist-ing of a geriatrician, a nurse and a social worker, listedthe patient’s problems, developed a care plan and coor-dinated preventive and management services, focusingon the maintenance of the patient’s functional status.Geriatric evaluation and management had no effects onsurvival, but significantly reduced functional declineduring hospitalization and improved mental health inoutpatients.

3

In acute hospital care, multidisciplinary

M Tanaka

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team work also improved patients’ outcome. Landefeld

et al

. demonstrated that acutely ill older patients caredfor in a special geriatric unit by the multidisciplinaryteam had better basic activities of daily living at the timeof discharge and were less frequently discharged toinstitutions for long-term care. Their team included aphysician, nurse, social worker, nutritionist and physicaltherapist.

4

These studies indicated that the use of thestandard protocol of comprehensive geriatric assess-ment (CGA) significantly improved activities of daily liv-ing and quality of life in both acutely and chronically illelderly patients. Sommers

et al

. asked if collaboration ofprimary care physicians in private practice with trainednurses and social workers could improve outcomes ofcommunity-dwelling elderly patients. They demon-strated that collaborative practice significantly reducedreadmission rate and mean office visits in chronically illold patients.

5

Interestingly, the significant differenceswere first observed in the second year of the study, andparticipants acknowledged that the first 12 months werelargely spent developing a trusting relationship with theteam. Moreover, the authors suggested a correlationbetween the number of nurse and social work contactsand both the service utilization and patient healthstatus. Therefore, establishing a trusting relationshipbetween patients and the team was a key factor in thesuccessful collaborative practice in community settings.

Collaborative team care for specific purposes

Injuries associated with hospitalization are more com-mon in older patients and they may be often prevent-able.

6

Among them, falls are a major source of morbidityand mortality in older patients. Approximately 30% ofelderly people living in the community and approxi-mately half of nursing home residents fall each year.

6

According to a study of hospitalized patients, the inci-dence of falls for older patients was 1.9%.

7

Close

et al

.analyzed whether a multidisciplinary assessment of eld-erly people with a history of falling could decrease therate of further falls. In the intervention group, a detailedmedical and occupational–therapy assessment was per-formed, advice and education was given and referral torelevant services was made if indicated. This interven-tion significantly reduced the risk of falling and thedecline in the Barthel score.

8

According to the study, theprimary cause of falling was frequently an environmen-tal hazard and many patients with a history of recentfalls had multiple risk factors, indicating the relevance ofa multidisciplinary assessment of intrinsic and extrinsicrisks. Tinetti

et al

. demonstrated that the assessment andmodification by nurses, physical therapists and primaryphysicians of known risk factors for falling, significantlyreduced the risk of this event,

9

while Stevens

et al

.reported that an intervention to reduce hazards in thehome alone did not have significant effects.

10

Fall pre-

vention may necessitate physical assessment and ther-apy including gait training, balance exercises andresistance exercises, in addition to education and theremoval of hazards.

Delirium is another major complication during hos-pitalization. The prevalence of delirium on admissionranges from 14% to 24% of older patients.

6

Sincedelirium prolongs the length of hospital stay andincreases morbidity and mortality, its prevention isimportant. Inouye

et al

. created a multicomponentstrategy for the prevention of delirium in hospitalizedolder patients. An interdisciplinary team (consisting ofa geriatric nurse specialist, two specialists trained forthis program, a therapeutic-recreation specialist, aphysical-therapy consultant, a geriatrician and trainedvolunteers) assessed and managed six risk factors fordelirium: cognitive impairment, sleep deprivation,immobility, visual impairment, hearing impairment anddehydration. The intervention strategy resulted in sig-nificant reductions in the number and duration of epi-sodes of delirium. However, the intervention had nosignificant effect on recurrence rates, indicating thatprimary prevention of delirium is most effective.

11

Depression is common in older people in the primarycare setting. Late-life depression is often recurrent, andis associated with functional morbidity, diminishedquality of life and increased risk of death.

12–14

Most olderpeople with depression are never treated by mentalhealth specialists, although they visit their primary carephysicians frequently. Unutzer

et al

. examined whetheraccess to a depression care manager could improve theoutcome of older people with depression. Depressioncare managers were trained nurses or psychologists,supervised by psychiatrists and primary care experts.They offered education, care management and supportof antidepressant management. The collaborative careresulted in significant reduction in depressive symp-toms, greater rates of depression treatment, more satis-faction with depressive care, lower depression severity,less functional impairment and a greater quality of life,suggesting that this approach is effective in the manage-ment of depression in primary care practices.

14

End of life care

Although population-based studies have suggested apreference for terminally ill patients dying at home,most of these patients die in institutions. Collaborativeteam care may be an effective strategy for filling this gap.Jordhoy

et al

. demonstrated that palliative team care andclose cooperation with the community health-care pro-fessionals enabled more patients to die at home.

15

Theirteam – two palliative-care nurses, a social worker, apriest, a nutritionist, physical therapist and physicians –made plans for treatment and care, and arranged ameeting with a family physician and a community

Multidisciplinary team approach

71

nurse. However, this approach made no significant dif-ferences in the time spent at home or the rate and lengthof hospital use. Home care may be a burden to patientsand families without continuous availability of specialistcare. This might be a reason for a high rate of admissionto hospital in both intervention and control groups inthis study. The authors concluded that a trained home-care team that provides 24 h service and takes fullresponsibility for the patients’ treatment would be nec-essary to increase time at home and reduce hospitaladmissions.

15

Chochinov

et al

. focused on the dignity of terminallyill patients. Although their patients received expert pal-liative care, nearly half of them reported at least someconcerns regarding dignity. Particularly, 7.5% of thepatients who reported that loss of dignity suffered withfar more psychological distress, symptom distress,depression and loss of will to live. Moreover, a deterio-ration in one’s appearance, a sense of being a burden toothers, needing assistance with bathing, requiring inpa-tient hospital care and having pain were the most sig-nificant issues related to loss of dignity. The authorssuggested that understanding dignity-concerns ofpatients could raise our sensitivity to many importantaspects of human pain and that dignity-conserving careneeds to become part of palliative care.

16

Patient and caregiver education

Several reports have indicated that patient educationand specialized follow up by a multidisciplinary teamwere an effective strategy for reducing the readmissionof patients with congestive heart failure. Rich

et al

.reported that intensive education about congestiveheart failure and treatment by an experienced cardio-vascular nurse, dietary instruction given by a dietitianand consultation with a social worker, improved qualityof life and reduced hospital use and medical costs inelderly patients with congestive heart failure.

17

Anotherstudy indicated that patient education and medicationevaluation by a clinical pharmacist improved the out-come of patients with congestive heart failure.

18

Sincecongestive heart failure is one of the most commonindications for hospitalization among elderly people,use of this kind of intervention could reduce costs forhealth care.

Caregiver education is particularly important for fam-ilies who take care of patients with dementia. They pro-vide care at the expense of their own physical and mentalhealth for sustained periods of time. Hepburn

et al

.developed a caregiver education and training program,focusing on information provision (information aboutthe disease and symptoms), concept development (stage-specific strategies for managing daily life and behavior),role clarification (caregiver’s role), belief clarification(beliefs about caregiving) and mastery-focused coaching

(comments and suggestions on caregivers’ reports).

19

This community-based 14 h education and training pro-gram significantly benefited caregivers in important out-come dimensions: depression, burden and reaction totheir care-receiver’s problem behaviors. Caregivers inthe treatment group also demonstrated better scoresregarding their attitudes to caregiving work. The authorssuggested that the education and training by a multi-disciplinary team resulted in a shift in beliefs that allowsfamily members to think strategically about how to pro-vide the best care for the care-receivers.

19

Student education

How well interdisciplinary team care improves patientoutcomes depends on how well team members can col-laborate. Rubin and Beckhard demonstrated factorsinfluencing the effectiveness of interdisciplinary careteams: definition of appropriate goals, clear role expec-tations for members, a flexible decision-making process,the establishment of open communication patterns andleadership and the ability of the team to treat itself.

20

Leipzig

et al

. performed an interesting survey about atti-tudes toward interdisciplinary team care among medicalresidents, nursing students and social work students.

21

Each group of students agreed that the team approachbenefits patients and is a productive use of time. How-ever, the most marked difference between medical res-idents and the other two trainees was observed in thephysician’s role on the team. Medical residents weremuch more inclined than nursing and social work stu-dents to agree that physicians are natural team leadersand have the final word on team decisions. More med-ical trainees also agreed that a team’s primary purpose isto assist physicians in achieving treatment goals forpatients. The authors suggested that the differences inattitudes towards mutual accountability for team deci-sions may be due to physician education and trainingnested within a hierarchical and unidisciplinary model.They concluded that exposure to interdisciplinaryteamwork and team decision-making should be consid-ered during medical school.

21

Conclusion

As discussed above, increasing evidence indicates thatinterdisciplinary teamwork is indispensable for today’smedical care. A collaborative team approach should bepromoted, including inpatient care planning and man-agement, prevention programs for medical injuries, dis-charge planning, patient and caregiver education andcooperative work with local healthcare professionals.Teaching hospitals should also provide a training pro-gram for medical, nursing and social work students topromote early exposure to interdisciplinary teamworkand team decision-making.

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