GPSCO Presentation to City of Ottawa Counsellors

Geriatric Psychiatry Community Services of
Services communautaires de géronto-psychiatrie
Vickie Demers
Clinical Coordinator
Program Description
• Community based mental health program
• Funded by the Ministry of Health and LongTerm Care
• Bilingual
• Case management model
• Client is seen at home by a case manager
• Interdisciplinary team with geriatric psychiatrists
Program Description
• Specialized geriatric psychiatry outreach team
• Individualised assessment and treatment in the
client’s home including retirement home
• Support caregiver/family through education, case
management and counseling
• Collaborate with family physicians and a multitude
of community agencies
• Provide education to professionals, students and
Improve the care of the elderly in the community
optimizing client’s mental health
enhancing client’s environment and quality of life
linking client to community resources
preventing unnecessary hospitalization
facilitating necessary hospitalization
offering support and education to client, caregivers, and
Program Staffing
Executive Director
Medical Director
Clinical Coordinator
Geriatric Psychiatrists (4)
Case managers ( RN, SW & OT ) (16, FTE:12.4)
Psychogeriatric Resource Consultant
Capacity Assessors
Medical Secretaries
Target Population
• Persons over 65 with mental health problems or
suffering from dementia complicated by behavioral or
psychological symptoms.
• Persons less than 65 with Alzheimer’s dementia or
frontotemporal dementia complicated by behavioral or
psychological symptoms.
• Persons must live in the Ottawa community (excluding
Long Term Care Homes). Persons who reside outside
of Ottawa can be seen for a psychiatric consultation.
No follow-up with case managers is available.
• Persons must be referred by a physician (exceptions
are made on a case by case basis).
Referral Sources
• Family physicians and other physicians
• Memory Disorder Clinic
• RGAP and other Community Programs and
• Hospitals
• Champlain Community Care Access Centre
• Mental Health Crisis Team
• Shelters & Police
Our Approach
Client centered approach
Collaborative care
Sensitive to the unique needs of the elderly
Case conferences as needed
What do we actually do?
• Establish diagnosis and provide follow-up
• Monitoring of treatment
(response/compliance/side effects)
• Provide education and support to family and/or
client (illness / services available / options re:
future planning)
• Facilitate acceptance of services and review
• Advocate for our clients
Common Diagnosis
• Psychiatric Diagnosis
• Anxiety
• Depression
• Psychotic disorder
• Dementia
• Alzheimer dementia with agitation
• Frontotemporal dementia with agression or
impulsive behaviours
• Lewy Body dementia with disturbing visual
Who not to refer
Client presenting with:
• memory problems without any
behavioural or psychological symptoms
• multiple unstable medical conditions
• depression but is less than 65 years of age
Geriatric Assessment
Outreach Team
Discharge planners
Residential facilities
Ottawa Mobile Crisis
Community Agencies
& support programs
Housing programs
Police and Shelters
• Elisabeth Bruyère Research
• Alzheimer Society of
• Geriatric Assessment Unit
• Acute care hospitals &
• Public Guardian & Trustee
• Lifestyle Enrichment for
Senior Adults (LESA)
Geriatric Psychiatry Community Services
of Ottawa
• Main focus:
– diagnosis psychiatric condition & follow up
– diagnosis and follow-up (dementia + behaviour
issues/ psychiatric symptoms)
• Referral from physician for psychiatric consults and
other professionals if there is already a diagnosis
• Emphasis is on consultation services (assessment) and
• In home assessment by counselors
• Disciplines: Geriatric Psychiatrist, Social Worker,
Nursing and Occupational Therapist
Memory Disorder Clinic
Main focus: diagnosis of dementia (any stage)
Referral from Physician
No age limitation
Function at a high level (no complex physical,
psychiatric, mental retardation, head injury etc.)
• Disciplines:
Geriatric Medicine
Geriatric Assessment Outreach Teams
• Main focus: diagnosis (dementia + concomitant medical
• Referral from physician, professional, family & client
• Age: over 60 yrs of age presenting with geriatric problems
• Emphasis is on multidisciplinary assessment for purpose of
• In home assessment (triage/screening for DH)
• Disciplines:
– Occupational Therapist
– Nursing
– Social Worker
– Physiotherapist
Case Presentation #1
62 yr old man
Memory impairment (MMSE 24/30)
Hypertension (under control)
History of TIA’s
Living alone and some difficulty managing
Case Presentation #2
77 yr old woman
Memory impairment (MMSE 22/30)
Many falls in last 6 months (wrist fracture in Nov 06)
OA (followed by rheumatologist)
Diabetes not well controlled
Many medications
Teary, lack of appetite, lack of sleep and little interest
Case Presentation #3
84 yr old woman
MMSE 26/30
Loss of husband 6 months ago
Geriatric Depression Scale 9/15
Lack appetite, lack of interest, depressed mood etc.
Breast Cancer (followed by Cancer Centre)
Case Presentation #4
• Couple: 79 yr old woman & 82 yr old man
• Wife diagnosed with AD (MMSE 18/30)
• Husband presents with cognitive difficulties (forgets
appt, minimizes wife’s problems)
• Wife is irritable, verbally aggressive
• No family
• Followed by family physician

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