When a 95-year-old woman living in a retirement home began experiencing frequent falls, paranoia, and rapid cognitive decline, her family feared for her safety and well-being. But thanks to the coordinated efforts of the GAIN (Geriatric Assessment and Intervention Network) team at Durham Community Health Centre, her story became one of resilience, recovery, and renewed quality of life.
A Complex Case Requiring Compassionate Coordination
The client, already living with moderate dementia and multiple chronic conditions, was facing escalating challenges: frequent falls, weight loss, behavioral symptoms, and medication complications. Her family, though supportive, struggled to manage her care from a distance.
The GAIN team stepped in with a comprehensive, interdisciplinary approach. Over two years, they collaborated with the client’s family, retirement home staff, and community healthcare providers—including a geriatrician, endocrinologist, and family physician—to deliver tailored, person-centered care.
Key Interventions and Outcomes
- Medication Optimization: The team discontinued medications contributing to falls and weight loss, introduced scheduled pain management, and adjusted treatments for behavioral symptoms.
- Behavioral and Environmental Strategies: Non-pharmacological approaches were used to manage paranoia and sleep disturbances, while environmental modifications helped reduce fall risk.
- Family and Staff Education: Ongoing education empowered both the family and retirement home staff to support the client’s evolving needs.
- Personal Support Worker (PSW) Integration: Initially resistant, the client eventually accepted PSW assistance, improving her safety and daily care.
- Long-Term Planning: With GAIN’s guidance, the family explored supportive living options, leading to a successful transition to a memory care unit.
A Measurable Impact
After targeted interventions, the client experienced no falls over a subsequent six-month period —a major milestone. She regained approximately 10 pounds over the year, reversing a troubling trend of weight loss. Now settled in a memory care unit, she is socially engaged, participating in activities, and thriving in a safer environment.
Why Specialized Geriatric Services Matter
This story is a powerful testament to the value of integrated, specialized geriatric care. Through persistent engagement, expert coordination, and a deep understanding of aging-related challenges, the GAIN team helped this client—and her family—navigate dementia with dignity, safety, and hope.
As Ontario’s population continues to age, stories like this underscore the urgent need for continued investment in specialized geriatric services that prioritize collaboration, compassion, and person-centered care.