1. Geriatric Psychiatry Community Services of Ottawa Services communautaires de géronto-psychiatrie d’Ottawa
G P S O C
Vickie Demers
Clinical Coordinator
S G P O

2. Program Description Community based mental health program
Funded by the Ministry of Health and Long-Term Care
Bilingual
Case management model
Client is seen at home by a case manager
Interdisciplinary team with geriatric psychiatrists

3. 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 community

4. Goals 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 family

5. 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

6. 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).

7. Referral Sources Family physicians and other physicians
Memory Disorder Clinic
RGAP and other Community Programs and Services
Hospitals
Champlain Community Care Access Centre (Ottawa)
Mental Health Crisis Team
Shelters & Police

8. Our Approach
Client centered approach
Collaborative care
Sensitive to the unique needs of the elderly
Bilingual
Case conferences as needed

9. 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 implementation
Advocate for our clients

10. Psychiatric Diagnosis
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 hallucinations

11. 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

12. Partnerships Geriatric Assessment Outreach Team (GAOT)
Discharge planners
CCAC
Residential facilities
Ottawa Mobile Crisis Team
Community Agencies & support programs
Housing programs
Police and Shelters
Elisabeth Bruyère Research Institute
Alzheimer Society of Ottawa
Geriatric Assessment Unit (GAU)
Acute care hospitals & ROMHG
Public Guardian & Trustee
Lifestyle Enrichment for Senior Adults (LESA)

13. 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 follow-up
In home assessment by counselors
Disciplines: Geriatric Psychiatrist, Social Worker, Nursing and Occupational Therapist

14. 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:
Neurology
Geriatric Medicine
Neuropsychology
Nursing

15. Geriatric Assessment Outreach Teams
Main focus: diagnosis (dementia + concomitant medical problems)
Referral from physician, professional, family & client
Age: over 60 yrs of age presenting with geriatric problems
Emphasis is on multidisciplinary assessment for purpose of diagnosis
In home assessment (triage/screening for DH)
Disciplines:
Occupational Therapist
Nursing
Social Worker
Physiotherapist

16. 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

17. Case Presentation #2 77 yr old woman Memory impairment (MMSE 22/30)
Many falls in last 6 months (wrist fracture in Nov 06)
Hypertension
OA (followed by rheumatologist)
Diabetes not well controlled
Many medications
Teary, lack of appetite, lack of sleep and little interest

18. 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)

19. 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