Caring for the elderly

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Helping seniors regain quality of life is all in a day’s work for Geriatrician Dr. David Cowan, who travels from Hamilton to Niagara six days a month to work in the Geriatric Assessment Program. “There is a very large group of frail, elderly people who do not have a voice in our society,” Dr. Cowan says. “The Geriatric Assessment Program is about getting elderly people out of hospital and back home, who otherwise wouldn’t leave hospital.” The program is also about providing the elderly with proper assessments and supports to keep them at home.

As our population ages, so does the need for geriatric health care. The Niagara Health System’s (NHS) Greater Niagara General Site in Niagara Falls has been providing Geriatric Assessment services for 13 years, but with limited resources to expand the program outside the community. The Niagara Falls program provides both an inpatient service and an outpatient assessment clinic.

Recent statistics show the Niagara Region has among the highest percentage of elderly residents in Canada. In response to the growing demand for geriatric services, the NHS recently expanded the location of services, and now, outpatient clinics are taking place in Welland and St. Catharines, as well as the hub Niagara Falls site.

Using a case management model, the NHS Geriatric Assessment Program provides a comprehensive physical, psychosocial and environmental needs assessment for Niagara’s senior population. Access to the service is by physician referral. This is a consultation service which combines the specialized geriatric skills of a program manager/clinical nurse specialist, geriatrician(s) and nurse specialist/case managers, explains Clinical Manager Wendy McPherson. “Patients are initially assessed in their home by the nurse specialist, who takes the patient’s history, including information on medications, falls, urinary continence, dementia, delirium, depression, and other psychiatric and health problems facing the elderly. A family member is asked to be present at the assessment, with the patient’s permission, to provide collateral information as well as to be involved in the patient’s care management. We work together to get a full picture of our patients’ issues and needs.”

Once the initial nursing assessment is completed, a summary report of the assessment is supplied to the referring physician by the nurse, Wendy explains. “The seniors we see at clinic cannot easily live in isolation and seldom manage without some kind of support system.” Patients are then seen by the Geriatrician at the outpatient clinic, who shares his/her consultation summary with the referring physician. From there, a care plan is developed through collaboration among the geriatric services team.

Dr. Cowan is one of four physicians providing consultation services to the program and is a full-time Assistant Professor of Medicine at McMaster University Medical School. “Niagara’s Geriatric Assessment Program is a highly-successful unit and it is team work that really makes the program successful,” he says. “Many of the patients we see are suffering from over-medication, depression or dementia. We do a lot of work to identify drug interactions that are giving people an adverse reaction.”Depression is a condition that can be devastating for the elderly. “It is under-recognized and many people don’t realize it can be treated,” Dr. Cowan says. “For many seniors, what is supposed to be a time of positive reflection on a long life often ends up being a very upsetting and distressing period as they near the end of their life. Prescribing the right medication and encouraging exercise are very real solutions to depression.”

Dementia or cognitive impairment is a frequent condition among patients of the Geriatric Assessment Program. Over-medication is sometimes part of the problem, says Dr. Cowan, and if changes can be made, dementia can lessen. “We do spend a lot of time with families to help them learn how to manage dementia, because it can be overwhelming for caregivers.”

“The team also provides outreach service for those unable to attend the hospital clinics by going to patients’ homes or to long term care facilities and retirement homes,” Wendy says. The nurse or case manager follows up with patients between clinic visits as required, to answer questions, provide direction for care management and provide caregiver support. Clinics are held monthly in St. Catharines and Welland. Niagara Falls started with monthly clinics and has grown to six to eight clinics per month. Usually 10-12 patients are seen at each clinic, depending on the complexity of their situation. “Newly-referred patients require a longer first appointment than do follow up appointments,” Wendy says. “In total, we see about 900 patients per year for initial assessments and follow-up clinic visits.”

In addition, the Geriatric Assessment Program provides inpatient assessments for the eight-bed Geriatric Assessment (inpatient) / Rehabilitation Unit at Greater Niagara General Site. The focus here for inpatients is to improve or maintain function so that the patient is able to return to their former pre-hospital admission environment. There is a dedicated nurse, extra physiotherapy and occupational therapy for these patients. Patients must be able to participate in the rehabilitation program and usually have some cognitive impairment. “Typically, 75 per cent of our inpatients return to their former place of residence after their hospital stay,” Wendy says.

“We’re proud of our Geriatric Assessment Program, and particularly pleased that, in these days of financial restraints, we have been able to expand the program to two other cities in our catchment area,” Wendy says. “Our program is looked upon by others as a model for providing effective geriatric care, and that wouldn’t be possible without the great team we’ve put together. We are fortunate to have a cadre of specialists at close hand to help us offer the program.”