Collaborative geriatric care supported an older adult with advanced frailty and delirium to return to the place where she felt safest.
For an older adult living with dementia and increasing frailty, repeated hospital admissions can be both clinically complex and deeply disruptive. One patient supported by the Geriatric Inpatient Consult Service at Brant Community Healthcare System experienced recurrent delirium associated with several medical conditions. Over time, her frailty progressed and each hospitalization introduced new risks to her independence and well-being.
Throughout these admissions, the patient and her family consistently expressed a preference for her to return home. The geriatric team worked alongside the patient, her family, the medical team and community partners to make that possible
A comprehensive, person-centred approach
The team completed a comprehensive geriatric assessment and developed recommendations addressing the patient’s medical, functional, cognitive and behavioural needs. The approach emphasized non-pharmacological strategies for delirium and responsive behaviours, including gentle persuasion, validation and measures to reduce the use of restraints, intravenous lines and other interventions that could increase distress.
The team also:
- Educated hospital staff and the patient’s family about delirium and dementia
- Initiated a referral to Behavioural Supports Ontario
- Reviewed and adjusted medication recommendations
- Supported rehabilitation
- Coordinated discharge planning around the patient’s changing needs
- Arranged geriatric outpatient follow-up after discharge
- Advocated for appropriate home and community supports
Family meetings and collaboration with social work and Ontario Health atHome helped the care team address safety concerns while continuing to honour the patient’s preference to return home.
Home, belonging and family connection
With coordinated geriatric, hospital and community support, the patient was able to return home following her admissions. She continued to live in the community with her family and subsequently received support from an outreach palliative care service.
For the patient, returning home meant safety, belonging and connection. For her son, it meant being able to continue caring for his mother in a familiar environment despite her advanced frailty. Said one family member “the Geriatric Team does a phenomenal job helping my return back home after each admission. You guys are fantastic.”
This story demonstrates how comprehensive geriatric assessment, family engagement and collaboration across hospital and community services can help align care with what matters most to an older adult.