June 30, 2025
When an 80-year-old man arrived at the hospital after two falls in 48 hours, his condition raised serious concerns—not just about his physical safety, but about his cognitive health, mobility, and the growing stress on his caregiver. The initial care provider team promptly involved the Geriatric Medicine Consult Team (GMCT) and the Geriatric Medicine Unit at the Ottawa Hospital. Thanks to the swift and comprehensive interventions of these specialized Geriatric Medicine teams, this patient and his family received the clarity, care, and support they urgently needed.
A Complex Case Requiring Specialized Insight
The patient presented with slurred speech, confusion, and repeated falls. Through the involvement and co-management of GMCT, it was discovered that the patient had a history of over 30 falls in the past year, and his wife, overwhelmed and unable to manage his increasing needs, reported behavioral changes and cognitive decline. A Comprehensive Geriatric Assessment revealed a multifaceted picture: suspected Lewy Body Dementia, untreated sleep apnea, chronic pain, and medication complexities.
Recognizing the need for continued specialized care, the GMCT transferred the patient to the Geriatric Medicine Unit, where a focused team addressed key geriatric domains: cognitive testing, pain management, polypharmacy, and fall prevention and management.
A Coordinated, Compassionate Response
The team’s interventions included:
- Diagnosis and Treatment: A suspected major neurocognitive disorder, likely vascular with features of Lewy Body Dementia, was diagnosed. Treatment with appropriate medication was initiated.
- Mobility and Safety: A proper gait aid was provided, and falls were attributed to cognitive decline rather than cardiac causes.
- Pain Management: A tailored pharmaceutical regimen was introduced, including a range of age appropriate medications along with topical treatments.
- Swallowing and Nutrition: A Speech-Language Pathologist assessed and supported safe eating strategies.
- Caregiver Support: The patient’s wife received education, respite planning, and community support referrals.
A Safe Return Home—and a Grateful Family
After just eight days, the patient was safely discharged home with a comprehensive follow-up plan and community supports in place. His family expressed deep gratitude for the thorough, compassionate care they received.
Why Specialized Geriatric Services Matter
This story exemplifies the critical role of specialized geriatric services in managing the complex, overlapping needs of older adults experiencing frailty, dementia and other conditions. Through interdisciplinary collaboration and patient-centered care, the GMCT and Geriatric Medicine Unit not only improved this patient’s health outcomes but also empowered his family with knowledge, resources, and hope.
At the regional level, coordination and clinical support for Ontario’s system of specialized geriatric services is facilitated by Regional Geriatric Programs (RGPs) and Regional Specialized Geriatric Services (RSGS), entities that keep critical clinical services for older adults humming along. In the Ottawa area (Champlain region), the Regional Geriatric Program of Eastern Ontario, one of the province’s first RGPs, connects the nearly 50 local specialized geriatric services with clinical expertise, evidence-based resources, education and research.
RGPs and RSGS entities form the backbone of Ontario’s clinical geriatric care system. These regional bodies provide strategic and operational leadership to ensure older adults receive integrated, high-quality, and specialized care across the province.
As our population ages, the need for such services will only grow. This story is a powerful reminder of the value of investing in specialized geriatric care—ensuring that older adults living with or at risk of complex health conditions like frailty, dementia and mental health concerns receive the dignity, safety, and support they deserve.