To implement a multidisciplinary approach to address geriatric syndromes in your clinical practice, establish a multidisciplinary team (MDT) including doctors, nurses, therapists, mental health practitioners, pharmacists, dietitians, specialists relevant to the patient's conditions, social workers, housing specialists, and voluntary sector practitioners to provide coordinated care NICE NG27.
Start comprehensive assessments of older people with complex needs at the point of admission or first contact, ideally in a specialist geriatric unit or setting, to identify health and social care needs NICE NG27.
Develop individualised management plans based on personalised assessments that consider multimorbidity, frailty, patient goals, preferences, and treatment burden to improve quality of life and reduce adverse events NICE NG56.
Coordinate care across settings by ensuring communication and information sharing between hospital-based and community-based MDTs, using accessible electronic data systems while respecting information governance NICE NG27.
Assign a named discharge coordinator or care coordinator responsible for managing transitions between care settings and acting as a central contact for the patient, family, and healthcare professionals NICE NG27.
Implement multifactorial interventions for common geriatric syndromes such as falls, including strength and balance training, home hazard assessments with follow-up interventions, vision assessments, and medication reviews with specialist input to reduce risks NICE CG161.
Review medications regularly, especially psychotropic drugs, to minimise risks such as falls and adverse drug interactions, particularly in patients with multimorbidity and polypharmacy NICE CG161,NICE NG56.
Encourage patient participation by discussing willingness to make changes and providing information in accessible formats and languages NICE CG161.