Sunnybrook and Women’s College Health Sciences Centre recently opened the doors of a multi-disciplinary memory clinic. The clinic assesses outpatients with a wide range of cognitive impairments using a combined diagnostic approach from three disciplines: geriatric psychiatry, geriatric medicine and cognitive neurology. The principal consultants who developed and run the clinic are Dr. Sandra Black, head of neurology, Dr. Heather MacDonald, geriatrician and medical director, Aging & Veterans, and Dr. Nathan Herrmann, head of geriatric psychiatry.
The clinic was primarily designed as a teaching tool for geriatric psychiatry, geriatric medicine, and cognitive neurology trainees. The trainees receive guidance from the three principal consultants, gain practical experience in managing patients with cognitive impairment, and learn about cognitive disorders from all three perspectives at once. “It is a very holistic approach to the assessment and management of dementia,” says Dr. Heather MacDonald. “Dementia is a multi-faceted illness, so the clinic was created to provide a unique educational environment for training physicians in Neurosciences, as well as an environment where patients will benefit from the specialties working together.”
The Multi-Disciplinary Memory Clinic is open on Mondays and has run weekly since mid October at the E2 Ambulatory Medicine Clinic area. New patients are assessed every week. They are referred to the clinic by physicians who require recommendations in the diagnosis and treatment of dementia, a disorder characterized by progressive cognitive difficulties that affect daily behaviour and functioning. In keeping with the more specialized nature of the clinic, the patients have more complicated dementias. They are likely to have other medical and psychiatric illnesses at the same time, or rare forms of dementia. The clinic sees three patients at each session.
The consultation begins with an interview and a questionnaire for the family or caregiver. This is followed by a physical exam and a detailed, standardized mental status exam, which looks at a number of areas of brain functionÑmemory, language, visual-spatial abilities, judgement. Once the assessment is complete, a case conference is held, where each case is reviewed by three trainees and three consulting doctors. Each resident presents their findings to the group, followed by discussion and a visit to the patient by the group. The results of the case conference are discussed with patients on the spot and recommendations are provided to the referring physicians with arrangements made for further follow-up as needed. The involvement of a social worker from S&W Specialized Geriatric Services provides families and patients with direction to supports and resources in the community.
The clinic is special because it is very unusual for all three disciplines (geriatric psychiatry, geriatric medicine, and cognitive neurology) to work together collaboratively in real time, and also because of the immediacy of the feedback to the patient. Dr. Sandra Black says, “We felt that this could be a more efficient way of diagnosing patients and reduce the duplication that patients experience when visiting physicians in different specialties at different times. It is a special clinic because the patient gets three consultations all at once with feedback right away. There is a synthesis that comes with having people problem-solving together. When the group gets back together, all the input becomes relevant.”
Dr. Herrmann agrees: “It is certainly an incredible learning opportunity for residents in these disciplines. They see people thinking on their feet and get to participate too.” Residents are given experience in administering cognitive tests, making immediate decisions and presenting their findings concisely to other physicians. “The situation is a bit more formal than what they might be used to on rounds because they must put themselves out there and state their diagnosis to a group of their peers and mentors,” says Dr. Black. “It is always a mutually respectful group, but there is also room for debate. Residents must decide what decisions they will fight for and what they won’t. It is during the discussion of diagnoses that residents pick up on things they might not have considered otherwise. They come away more appreciative of the perspectives.”