Long-term relationships and interdisciplinary geriatric care helped an older adult living with dementia remain in their preferred living environment.
Six years ago, an older adult was referred to a Geriatric Outreach Team of Couchiching Family Health Team/North Simcoe Muskoka Specialized Geriatric Services because of cognitive concerns, declining function, recurrent falls, caregiver stress and mental health symptoms that had not yet been clearly understood. At the time, the client lived with their spouse in a multi-level home and received support from a nearby daughter. The client’s care needs were increasing, and the family reported feeling overwhelmed.
The Geriatric Outreach Team responded with comprehensive interdisciplinary assessment, treatment and follow-up. As the client’s needs evolved, the team adapted its approach while continuing to work toward a consistent goal: helping the client remain as safe, independent and engaged as possible.
Care that evolved with the person
Occupational therapy assessments identified opportunities to improve safety through mobility aids, stair railings, bathroom equipment, fall-alert technology and other environmental modifications. Medication reviews helped reduce polypharmacy and optimize medications that could affect cognition, mood and mobility.
The team also connected the client and family with:
- Geriatric psychiatry for diagnostic clarification and treatment recommendations
-
Counselling
- Physiotherapy to improve strength, balance and mobility
- Personal support services through Ontario Health atHome
- An adult day program offering meaningful engagement and caregiver respite
- Ongoing geriatric, nursing and occupational therapy follow-up
As the clinical picture became clearer, the client was diagnosed with Lewy body dementia. Ongoing education helped the client and family better understand the condition and prepare for future care needs.
Building trust and supporting change
Initially, the client was reluctant to accept recommendations such as using a walker and hearing aids or receiving personal support services. Consistent education, repeated conversations and trusting relationships with the interdisciplinary team helped the client gradually become more receptive to these supports. Coordinated geriatric medicine, geriatric psychiatry, counselling, medication management and supportive programming contributed to greater mental health stability. Following a move to a retirement home, the client developed friendships and began participating regularly in social activities.
Recovery through collaboration
Over the six years, the client experienced several medical setbacks, including delirium, COVID-19, recurrent falls and a fracture. At one point, a major decline in mobility led to full-time wheelchair use and transfers with a mechanical lift, raising concern that a move to long-term care might be required. Through the combined efforts of the client, family, retirement home staff, physiotherapy and the Geriatric Outreach Team, the client regained the ability to walk. The client participated in rehabilitation and returned to the retirement home. Physiotherapy continues to support strength, mobility and independence.
Across the six years of follow-up, the client experienced improved mental health stability, optimized medications and communication, and repeated recovery of mobility following periods of decline. Community services and the move to a retirement home also substantially reduced caregiver burden. Most importantly, the client has continued living in the retirement home, consistent with the client’s and family’s primary goal. As the team’s geriatrician described it, the client’s progress has been “A remarkable recovery.”
This story shows the value of sustained relationships, repeated reassessment and integrated care across geriatric medicine, geriatric psychiatry, rehabilitation, primary care, community services and supportive housing.