Dr. Tarek Rajji recalls a CAMH patient of his who has been living with a delusional disorder for years. In the recent past, something changed. In her “late 60s, early 70s” she began having memory problems on top of her existing mental health issues.
“She was an accountant and she started having problems managing her work...so her daughter brought her in because of her concerns regarding memory,” says Dr. Rajji.
The patient was brought in for assessment at CAMH’s Memory Clinic, one of several clinics under CAMH’s Geriatric Outpatient Clinics and Services.
Dr. Rajji is the Chief of Geriatric Psychiatry and the Medical Head of CAMH’s Geriatric Outpatient Clinics and Services. “We see patients who have primarily a memory disorder or a memory complaint or we could see patients with a longstanding mental illness and their physician or their family members are noticing memory problems on top of their existing mental illness.”
(L to R) Memory Clinic staff: Registered Nurse Marie Smith, Social Worker Esther Yoo-Parlan, Geriatric Outpatient Clinics and Services manager Joydip Banerjee, Chief of Geriatric Psychiatry Dr. Tarek Rajji, geriatric psychiatrist Dr. Sanjeev Kumar, project coordinator Rita Desai
When patients come into the Memory Clinic, they see staff like Dr. Sanjeev Kumar, a geriatric psychiatrist. He says one of the most unique aspects of CAMH’s clinic is that, unlike memory clinics at other Toronto-area hospitals, it has virtually no wait time to get in.
“One of the major limitations of other memory clinics is wait times. People have to wait six months, eight months or even a year. Two to four weeks is our time now and we want to keep it that way.”
Patients can refer themselves, or they can be referred by a physician. Clinic staff include behavioural neurologists, occupational therapists, social workers, nurses and geriatric psychiatrists, all of whom work together to provide the best care. “We have clinicians and staff that have specialized in this for a long time and we have access to a rich wealth of interdisciplinary expertise,” says Joydip Banerjee, manager of CAMH’s Geriatric Outpatient Clinics and Services.
A unique opportunity patients have at CAMH is the range of options offered. Patients at the Memory Clinic can choose to participate in research studies to access novel interventions, like magnetic brain stimulation.
“Because of our academic nature and our close integration with research, we are only one of a few places in the world where we’re researching neurophysiology of dementias and inventing new targeted and safer interventions, for example, magnetic stimulation of the brain,” says Dr. Kumar. “These interventions which we are researching are very focused and safe and our hope is that these interventions will be much safer than the medications.”
CAMH is also in the process of developing an Integrated Care Pathway (ICP) for the Memory Clinic to provide more streamlined care. An integrated care pathway is a system where clinicians from multiple disciplines follow a set of best practices, using evidence-based interventions, to achieve the best outcome possible for an individual patient.
Dr. Kumar is leading the Memory Clinic Pathway committee in developing this ICP.
“One thing about memory disorders is that most of them are neurodegenerative in nature. Many clients will get worse eventually and there may not be a very good medical treatment available in many cases, so it’s not that you just prescribe a medication. You have to support the client from different aspects of life.”
In order to provide such support, interdisciplinary teamwork is key. Rita Desai is a project coordinator for the ICP project. “We have a neuropsychological associate...social work and occupational therapy...nursing is also part of the design. Now we’re figuring out what their roles are, what are the interventions they can provide to this patient population.”
CAMH is also doing work to develop new interventions to prevent dementia, thanks to the hospital receiving the largest ever grant funded in Canada to prevent Alzheimer’s dementia. The grant is funded by Brain Canada and the Chagnon Family.
“The advantage of preventing dementia is that we would be intervening before the damage has happened to the brain from dementia. We are using novel brain stimulation and cognitive training methods to prevent cognitive decline and dementia among older persons with depression or mild cognitive impairment,” says Dr. Rajji. This is a five-year study that includes four other major hospitals in Toronto: Baycrest, St. Michael’s, Sunnybrook, and the University Health Network.
Dr. Rajji points out how important it is to have an interdisciplinary team to help not only the patient, but also their family, such as in the case of the accountant.
“Letting go of her finances was quite traumatic. The patient would say, ‘Why am I supposed to let my daughter pay my bills? Or take over my bank accounts?’ Then there were the challenges with the memory problem itself,” says Dr. Rajji.
“This lady was feeling confident, she’s been doing it for years...so trying to conceptualize that she can’t depend on her memory, it’s challenging and distressful for her and her family.” A big part of dementia care is providing support, and the Memory Clinic helps families manoeuvre the legal and financial systems as well as connecting them with agencies that can help manage dementia for their loved ones.
“We helped her move out of her house…[she] moved into living with her family, [we] provided some support for the family so they were able to manage the finances of this lady.”
“When I saw them a couple of weeks ago, the patient is well aware she has memory problems,” says Dr. Rajji. “She came to me after spending a day in a day program. I asked her what she did that day. She had no idea what she did just two hours before, but she says she is content and living in the moment.”