Practice spotlight: Collaborative care of the elderly

Abstract

The Centre for Health Care of the Elderly is a multiservice interdisciplinary program within the Capital District Health Authority of Nova Scotia. The program encompasses outpatient and inpatient care, and its cornerstone is comprehensive interdisciplinary assessment, treatment, and education of frail older persons and their caregivers. Outpatient services include the Memory Disability Clinic, which specializes in assessing and managing cognitive impairment, and the Community Outreach Program, which provides comprehensive geriatric assessment in the patient’s home or a long-term care facility. The outpatient team consists of a pharmacist (Susan Bowles), geriatricians, nurse practitioners, registered nurses, and social workers. The Memory Disability Clinic was established in the early 1980s, the team originally consisting of geriatricians and registered nurses. The Community Outreach Program was established about 10 years later, in recognition of the fact that for some individuals, performing assessments in their own home provides better insight into their problems. Approximately 2000 patients are seen annually in the Memory Disability Clinic and 300 patients through the Community Outreach Program. Susan Bowles joined the team for these programs in 2002, when Brian Tuttle, then Director of Pharmacy, and Dr Colin Powell, former Division Head of Geriatric Medicine, made an effective argument for reallocation of funds from another clinical area. The essence of this argument was the aging of the Nova Scotia population, the impact of drug-related problems on hospital admissions of older persons, and the body of evidence supporting the role of pharmacists in the care of elderly people. Patients are referred to geriatric outpatient services by their primary care provider, with referrals triaged according to complexity and urgency. A comprehensive geriatric assessment consists of a thorough history (cognitive, functional, medical, medication, and social), review of laboratory results, detailed cognitive and physical examinations, and an assessment of mobility. During an assessment, one team member obtains collateral information from family or caregivers, while the other team member sees the patient. If the pharmacist sees the patient, she is responsible for all aspects of the history and physical, cognitive, and mobility assessments. The physical examination, with particular emphasis on the neurologic and musculoskeletal systems, is targeted to identify findings suggestive of disease or drug effects that may be presenting atypically as cognitive or functional decline. The cognitive assessment consists of a battery of standardized tests to determine if a memory problem is present and, if such a problem is identified, its most likely cause. The medication history is an essential component of the geriatric assessment, as drugs are often overlooked as a contributing factor to cognitive and functional decline in this population. Once the assessment is complete, the case is reviewed with the attending geriatrician. This process involves discussion of the overall impression, the need for referral to other disciplines (e.g., physiotherapy or social work) or geriatric services (e.g., home care, seniors mental health, or geriatric day hospital), the need for further testing (e.g., a neuropsychologic assessment), and a treatment and monitoring plan (which often includes discontinuing medications). The pharmacist and geriatrician then meet with the patient and family to review the diagnosis (during the first assessment) or progress (during follow-up assessments), the need for other services or testing, and the treatment plan. After the visit, the pharmacist dictates a detailed consultation letter to the primary care provider, which is reviewed and signed off by the geriatrician. At present, Dr Bowles devotes 2 days per week to outpatient programs, with 1 day every 2 weeks set aside for the