For 20 years, the team at the Dorothy Macham Home (DMH) has been caring for residents who are experiencing more challenging behaviours due to Alzheimer’s disease or other dementias — modelling a more progressive individualized approach to care.
Modelled on the Adards Nursing Home in Tasmania, the DMH looks like a one-story house with ten private rooms, an accessible home-like kitchen and dining room, and two enclosed secure gardens.
It was a radical shift from traditional behaviour assessment unit models when it first opened in May 2001, and is currently one of only a few of its kind in the country.
– Andre Picard, referring to the Dorothy Macham Home, in his new book ‘Neglected No More,’ 2021.
“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,” says Dr. Jocelyn Charles, founder of the DMH and medical director of the Sunnybrook Veterans Centre, where the DMH is housed. “To enhance quality of life, this environment needs to be non-stressful, constant, familiar and safe.”
Recreation therapist Rhonda Latchford was part of the design team for DMH before its opening: “There is lots of sensory stimulation, and much of it is based around the kitchen where we bake up deliciously aromatic treats like brownies and host ‘happy hours’ that promote chatter and laughter, lightening the mood.” Outside, a large patio space is used for gardening, bird and squirrel watching and soaking up a little sun.
Other home-like features – including a fireplace, fish tank, and large garden windows – are balanced with concealed clinical equipment and safety features such as two means of exiting each room, floor sensors in bedrooms to detect entrance by another resident, and safe appliances in the kitchen.
All locked doors are disguised, and an unlocked door is close by to minimize frustration associated with a sense of confinement. An indoor wandering path allows residents to move around common areas and has been shown to lower levels of agitation.
“When not managed, residents with behavioural symptoms of dementia can get physically aggressive a few times a day to several times an hour, some receiving mild to moderate injuries as a result of the aggressive incidents,” says Dr. Charles. “The environment then becomes increasingly important as cognition declines.”
Another key component to the DMH’s approach is tailoring care and programming to the needs and preferences of the individual residents. Staff members take the extra time to get to know the residents and translate that knowledge to other members of the team.
“I had one resident who was agitated and refusing care, nothing I did was working,” says nurse Rhona Green. Remembering that the resident loved music, Rhona called in a music therapist. “The singing calmed her and changed her whole frame of mind. It helped so much as I was able to resume her care without any incident.”
She recalls another resident who had sensitive toes. Unable to tell his nurses that something hurt, he would lash out. Once aware of this, Rhona informed the other staff. “You get to know individuals and we try to share what we know about each individual’s quirks to help make the resident comfortable and to help things run as smoothly as possible.”
On the recreational end, Rhonda provides one-on-one interaction with the residents and organizes small group activities such as weekly barbecues on the patio, pie socials, and holiday parties, as well as community outings such as bus trips and Christmas lights tours. “I had tried to get a resident pet – we even had two bunnies once: ‘Sunny’ and ‘Brook.’”
More recently with the pandemic, there’s been much more virtual connections to help connect residents with their families and the outside world. “As external entertainers are not yet able to return to the facility, we’re using other methods to bring the entertainment in right here at home,” says Rhonda.
Some favourite activities include listening to Glen Miller and Judy Garland, playing virtual bingo, and watching sports. During Easter week, the unit participated in its first virtual mass over Zoom direct from the Sunnybrook chapel.
“The DMH is a safe and supportive home where the entire team is dedicated to assisting the residents live their optimal life.”
– Rhonda Latchford, recreation therapist
There are of course the challenges to their efforts. “Long-term care residents with dementia commonly exhibit behaviours that disrupt the lives of other residents and increase the complexity of their care,” says Evelyn Babcock, patient care manager of the home.
“Rhonda may want to do something with a small group, but individual residents can sometimes get jealous, as they love the RT but they don’t always get along with each other. They don’t always remember what, but they remember there was something about the other person that bothered them.”
A common example is when a resident, in their confusion, may try to get into another resident’s bed, starting an argument and often leaving everyone upset. “They can hang on to it and don’t trust the other resident,” says Rhonda, “so we need to navigate these things, such as where you place people, for example, is important.”
Rhona recalls how in the earlier days, the Veteran residents were a younger population and therefore generally more ambulatory, walking around all over and into each other’s rooms.
“You would try to convince them but it didn’t make any sense to them, so there were a lot more altercations,” she explains. “There’s always been a recognition on our team that it’s not the resident’s fault they have this disease and need care, and you must go with that, even when a resident becomes verbally or physically abusive with their nurse, which occurs frequently. One sometimes needs to walk away (from the immediate situation) when things get overwhelming and get support from colleagues.” In some cases, the use of medication is required in consultation with the team’s physician, geriatric psychiatrist and pharmacist. “We work together as a team, and with the family.”
Language or cultural barriers can contribute to the challenges. “You have to take time for that relationship to build,” says Rhona. “We rely on each other a lot; there are staff who can speak Russian, Italian, Korean, Chinese. There’s a nice feeling of community and helping each other out here; anyone or anything that needs help, we’re fortunate everyone comes together.”
The resident is always at the forefront, she explains: “I try to ask myself ‘How would I feel?’ and try to treat them the same way. It’s how I was brought up in my earlier years in Jamaica, it was ingrained in me to always give lots of respect to our elders, this is their home.”
She provides the example of paying attention to simple details like mouth care and shaving. “They also need to look good to feel good. We don’t know how they were living in their past life. You have to take pride in what you do and give them the best care, so when you finish, you know you did the best you could for these patients. They’re like family. This is a journey in life, a pathway for them and you give your best to it.”