By Dr. Jocelyn Charles
Dementia is the most common reason for placement in long term care in Ontario, particularly when associated with behavioural symptoms. Long-term care residents with dementia commonly exhibit behaviours that disrupt the lives of other residents and increase the complexity of their care. Behavioural and psychological symptoms of dementia (BPSD), defined as signs and symptoms of disturbed perception, thought content, mood, or behaviour, include: agitation, depression, apathy, repetitive questioning, psychosis, aggression, sleep problems, wandering, and a variety of socially inappropriate behaviors. One or more symptoms of BPSD will affect nearly all people with dementia during their illness, with the most common symptoms being depression, apathy, and anxiety. In a review of BPSD-focused studies, the prevalence of one or more BPSD symptom in long term care residents was 78 per cent.
Canada’s war veterans are predominantly male, with military service-related physical and psychological injuries, and have a higher prevalence of physically aggressive behaviours. At the Sunnybrook Health Sciences Centre Veterans Centre, 53 per cent of veterans have a diagnosis of dementia. With the increasing number of long term care residents with BPSD, and in recognition of the increasing importance of the environment as cognition declines, many long-term care homes have designed supportive and therapeutic environments. In 1996, a study of 186 Sunnybrook veterans with dementia using the Cohen-Mansfield Agitation Inventory, found that 43 veterans (23%) had significant behavioural symptoms. Of these, 33 (76%) were physically aggressive a few times a day to several times an hour. For the same group of veterans, using the Overt Aggression Scale, over a one week period, 10 veterans received mild to moderate injuries as a result of aggressive incidents. With the growing number of veterans with dementia and associated BPSD, the Sunnybrook Veterans Centre opened the Dorothy Macham Home (DMH) in Toronto, Canada, in May of 2001. DMH is an innovative care facility specifically designed for veterans with BPSD.
The DMH model of care represents a radical shift from the traditional “behaviour assessment unit” model to a more progressive, individualized “living” model, and was modeled on the ADARDS Nursing Home in Tasmania. The primary focus of the home is to provide veterans with a therapeutic place to live out the stage of their dementing illness when disruptive behaviours are prevalent. To enhance quality of life, this environment needs to be non-stressful, constant, familiar, and safe.
Designed with local and international clinician and architect input, DMH looks like a one-story house, with ten private rooms, an accessible home-like kitchen and dining room, and an enclosed, secure garden. An indoor wandering path allows residents to move around common areas; the provision this type of path has been associated with lower levels of agitation among people with dementia. All locked doors are disguised, and an unlocked door is close by to minimize frustration associated with a sense of confinement. Home-like features, including a fireplace, fish tank, large garden windows, and concealed clinical equipment, are balanced with safety features, including two means of exiting each room, floor sensors in bedrooms to detect entrance by another resident, and safe appliances in the kitchen. In recognition that some veterans were prisoners of war, the garden fence was concealed with shrubs to avoid this visual reminder. The all-professional nursing staff was selected through a behaviour-based interview process and specifically trained to provide flexible, needs-based care, with a ratio of 1:3.3 from 700-2300h and 1:5 from 2300-700h. The care team also includes recreation, creative arts and music therapists, spiritual care, a family physician, and a geriatric psychiatrist. A broader interprofessional consulting team is involved as necessary. Programming is flexible and tailored to the needs and preferences of the individual veterans.
Following the opening of the DMH in 2001, there was a significant decrease in behaviour-related incidents on the six Dementia Support units. This could be attributed to the removal of the most aggressive residents from the Dementia Support units to DMH. In addition the frequency of resident behaviour-related employee incident reports dropped by 70 per cent in the dementia support units. This drop was maintained at 28 incidents (for staff caring for 190 residents) in 2008 and increased to 60 incidents in 2017 (for staff caring for 232 residents). The DMH staff reported 21 and 10 resident behaviour-related employee incidents in 2008 and 2017 respectively. Only no or minor harm resulted from all employee incidents.
The DMH model as a whole, including therapeutic design, staff characteristics and approach, and staffing ratio, reduced behaviour-related incidents and injuries to both residents and staff on the Dementia Support units over a 16-year period. Ensuring adequate access to these specialized beds is a key success factor for maintaining reduced incident rates and needs-based care for people with behavioural and psychological symptoms of dementia.
Dr. Jocelyn Charles is the Medical Director, Veterans Centre, Sunnybrook Health Sciences Centre.