Guest editorial: Geriatric Psychiatry 2011, Part 2: Addressing cognitive problems

In this second part of a two-part theme issue on geriatric psychiatry, four articles focus on effective care for seniors with cognitive problems. 

In the first article, Dr Phil Lee and colleagues review the evidence for cholinesterase inhibitors and provide an update on the BC Alzheimer’s Drug Therapy Initiative (ADTI) re­search program. 

In the second article, Dr Peter Chan addresses “the confusion about confusion” by reviewing causes of delirium in seniors and giving up-to-date evidence-based treatment approaches. He also provides a list of clinician resources for continuing professional development as well as resources for family education. 

In the third article, neuropsychologist Dr Darcy Cox discusses the use of neuropsychological testing to clarify various diagnoses. Dr Cox states that although the Montreal Cognitive As­sessment (MoCA) is the strongest screening tool for early cognitive impairment, the Mini-Mental State Exam (MMSE) is also useful. (It is worth noting that when the ADTI began, the MoCA had not yet been widely adopted by family physicians in BC, and it was felt that the MMSE, which was already in common use, would be the more appropriate instrument.) 

In the fourth and final article, Dr Sandi Culo addresses the very challenging issue of risk assessment in cases of potential self-neglect or abuse, and the need for community agencies to work together in complicated cases.

The articles all highlight the need to provide primary care physicians with effective and accessible continuing medical education to help optimize their practices in dementia care. Because we know interactive techniques (i.e., case-based workshops) are generally more effective in improving physician behavior and patient outcomes, the UBC Continuing Professional Development (UBC CPD) Dementia Education Strategy[1] developed and delivered workshops to physicians in 39 BC communities from 2008 to 2010. 

Guided by a facilitator, the physician participants discussed dementia management, driving, patients living at risk, and related issues based on the workshop cases and the participants’ clinical experiences. The workshops increased the physicians’ awareness of provincial clinical practice guidelines on cognitive impairment and appropriate de­mentia care. 

The physician participants rated the workshops positively. They re­ported an increased use of cognitive assessment tools, as well as increased confidence in managing patients with dementia following the workshops. Furthermore, findings from secondary analyses of BC Pharmacare aggregated data comparing communities where workshops did and did not take place suggest that a greater number of physicians subsequently enrolled in the Alzheimer’s Drug Therapy Initiative in local health areas where workshops took place. 

The physicians from workshop communities submitted a greater number of Special Authority forms compared with physicians from other communities, which implied adequate cognitive assessments of patients were done by the physicians. Results also suggest that workshops demonstrating the use of clinical tools can improve physician practice performance.[1]

The Dementia Education Project (www.ubccpd.ca/Projects/DementiaEducation.htm) is continuing the work outlined by the Dementia Education Strategy.[2] In order to care for frail seniors with cognitive problems, all relevant health care professionals need to work together to integrate care and to collaborate with each other to focus on person-centred, evidence-based, community-supported care plans.

Geriatric mental health professionals look forward to continued collaborations and future initiatives with primary care physicians that will permit delivery of best-practice care for seniors with mental health problems. 
—Martha Donnelly, MD, CCFP, FRCPC
Head, Geriatric Psychiatry Program
Department of Psychiatry
University of British Columbia
Head, Special Interest Focused Practice Program
Department of Family Practice, University of British Columbia

References

1. Lynn B, Maultsaid D, Bluman B. Dementia education strategy for BC physicians 2007-2010: Final report. 2010. Accessed 4 July 2011. www.ubccpd.ca/__shared/assets/Dementia_Final_Report_ecopy4149.pdf.
2. Friesenk, Harrigan ML. British Columbia dementia education framework. 2009. Accessed 4 July 2011. www.fraserhealth.ca/media/Dementia%20Education%20Framework%20Final%20Report%20May%2013%202009.pdf