Unique as a Finger Print

The process of treating people with dementia is an arduous and, in many ways, unique one.

Considering the varied ways that dementia affects people and the constantly changing nature of the condition, it takes a particular kind of person to care for dementia patients well.

Village Nursing Home took all of these factors into account when structuring the “Person-Centered Therapeutic Recreation Dementia Program” a year and a half ago.

“We went through a whole process in selecting nurses,” said Aimee Wilson, who is director of therapeutic recreation, volunteer services and pastoral care at Village Nursing Home. “First we did an internal posting explaining the program and what kind of characteristics were needed. Then there was an application and interview process. We put people in different scenarios to see how they would react.”

Once selected, the staff of the dementia unit was put through a training process in May of 2006, run by Linda Buettner and Suzanne Fitzsimmons, who co-authored the book Dementia Practice Guidelines. Everyone who was to work hands-on with residents in the new program was trained, from the certified nursing assistants (CNA) to supervising staff to social workers and recreational therapists. All of the training was geared to the specifics of dementia and the staff came to know the types, history and process of the condition.

The results achieved by the dementia-specific training was in evidence on a recent afternoon on the third floor of the Village Nursing Home. This floor is dedicated exclusively to dementia patients and all of the sights and sounds are distinct and vastly different from the rest of the building. From one resident’s room came the soft sound of trumpet playing — the tune a 1940’s standard. Many of the residents were out of their rooms sitting in the hallways, quietly handling an old piece of memorabilia or, in one woman’s case, a stuffed cat that she pet softly.

The walls are a fresh and lively bright yellow and are adorned with all sorts of art pieces containing movable locks and latches.

“That’s touchable art,” Wilson said, pointing to a wooden frame with some knobs and buttons on it. “Residents can interact with them, it’s a diversional technique.”

Walking through the floor, Wilson pointed out various adornments, all period appropriate, seeking to match the youthful days of the unit’s residents. There are old movie posters and recognizable artwork from various eras.

“Every resident has one of these,” Wilson said, pointing to a small box, with personal photos framed inside. She used one as an example, with its photographs showing a resident when she was in her twenties, along with a more recent picture. “She probably won’t recognize what she looks like now,” Wilson said of the resident, “but she will see herself in the older picture and be able to identify herself. There’s a nostalgia component. It increases their comfort level for the floor to feel homey and recognizable.”

That emphasis on comfort and flexibility is the centerpiece of Village Nursing Home’s philosophy on dementia care. The idea is not to force residents into anything rigid, but to acknowledge the uniqueness of each case and then tailor each person’s daily activities to make sure the resident is at ease in his or her surroundings. The option to interact with others is always available, but staff also have residents perform small tasks by themselves, tasks they remember how to do, with the idea being that this bit of remembering will help residents cope with their condition.

“The activity program is completely individualized,” Wilson explained. “People read sometimes or draw or fold laundry. Every resident has a personal CD player and headphones to listen to their favorite old songs.”

Evidence of the very open structure of a resident’s day was everywhere. One woman was knitting by herself, a few other people were sitting quietly in a common room looking out the windows onto the street. Also in the common room was a sight you don’t see that often: A member of staff and a resident were holding each other gently in the middle of the room and dancing a waltz to a classic song. They swayed back and forth, both smiling, with other residents occasionally looking up to observe them. Dancing was what that particular resident wanted to do that afternoon and so it became her activity.

This tableau served as a perfect explanation for why the screening process to work with dementia residents had to be so heightened and specific. The largest part of the caring responsibility falls on the shoulders of the CNAs who, to make their residents happy, will dance or do whatever it is that triggers a positive response. They get to know their patients in an incredibly detailed way.

“All dementia patients have different needs, so it’s up to us to cater to them in different ways,” said Cynthia Burke, a rehabilitation aide. “You need patience, understanding and compassion to work in this field.”

Burke has worked as a CNA for Village Care for 34 years and has experienced just about anything there is to experience in the field. It might seem to be a bit late in her career for her to try out for the dementia program. Instead, she said she saw it as an opportunity, where she felt she could put to use all of the skills that she had learned in her career.

“It was a big change, but I’m happy with it,” she said with a smile.

She spoke along with two of her colleagues as they set out an afternoon snack for the residents in the common room. All agreed that the work they do in the dementia unit brought with it a higher level of community. Five CNAs usually work the day shift together and it’s up to them to work as a team and make the day go smoothly. All of them were certainly in agreement on one thing, that there were special qualities that a person simply could not do this job without.

“I’m a very patient person,” said Marie Casseus, another CNA on duty. “If they fight me, I accept it and try and change things to make them happy. I think that I learn a lot from them, too. Like with Millie [she pointed to a resident waiting for her snack.] When she doesn’t want to wake up in the morning, I have a little song that I always sing for her and then she wakes up and she laughs.”

As a demonstration, Casseus unabashedly broke out into the first few bars of the tune and residents slowly looked up and smiled around her, recognizing the sound and enjoying it. Casseus and her colleagues are the people that these dementia residents see most in their world and they interact with a level of ease that comes from knowing one another and earning trust.

“We do build a camaraderie,” said Charmaine Jackson, another CNA who has been at Village Nursing Home for five years. “It’s challenging, sometimes, when they’re asking for their mother. Sometimes they get depressed, sometimes they cry. You just need to find the right words to say to them. Because everybody is different, you get to know and understand them. I think this is a good program. People need that special care. They need love and attention.”

Each of these CNAs spoke of a personal connection that they felt to the residents they work with. That seemed to be much of what their job was about, building relationships that are as strong as possible. They are also encouraged to work together with the rest of the staff and the nursing home supervisors. Instead of just taking their instructions and going to do the job, the dementia CNAs report bi-weekly to each other and their supervisors, going over how they can tweak and adjust their approaches to make their work as successful as possible.

“We meet as a team to discuss anything,” said Jackson. “We talk about changes in residents, how we feel about different things that have been happening, what we need to change.”

“It’s nice to have [the meetings],” Casseus added. “People listen to our opinions and we all work together. You get to share the battle.”

That sense of teamwork and leadership can also be attributed to the training and preparation that Village Nursing Home gave to the staff before embarking on the dementia unit. “Our staff all received training on how to coach one another and problem solving skills,” Wilson said. “The enhancement of the team feeling is very important. Nurses have to become more effective as coaches, not micro-managers. What we want is to have discussion and cooperation where it’s not ‘don’t do it this way,’ and instead it’s ‘let’s see how we can make this better.’”

Wilson went on to talk about how she has seen a consistent improvement as the dementia unit grew into its own and that the staff continues to display more and more of the effects of their training.

“What we continue to see is more preparedness,” she said. “They all have a certain level of patience and tolerance. Their training dealt with apathy and agitation and how to work around that, so our staff really know how to motivate.”

All of this training was made possible by a state grant, which is what makes the dementia program at Village Nursing Home so distinct. The grant was for “Developing a Person-Centered Therapeutic Recreation Dementia Program.” The name of the grant holds in it a certain set of guidelines for the forward-thinking program that has been created. The program has to be manageable enough in space and population to really be able to center the treatment around each individual. While the 40 residents that the dementia unit has is not small by any means, the floor feels very contained and the ratio of 5 CNAs to those 40 residents makes personalizing the day very possible.

“One component of the grant was that all of the residents in our program needed to have a diagnosis of dementia and be able to benefit from an on-going program of activities,” Wilson explained. “A person with end-stage Alzheimer’s, perhaps bed-bound, may not be appropriate for this program, and would be a better fit for a palliative care program. We encourage independence and choice, therefore, residents can go to the main dining room if they wish to participate in larger groups or have their meals there.”

The dementia unit is, in many ways, built around straddling lines. They encourage interaction and activity, but do not force it. They treat dementia patients with knowledge and techniques specific to the nature of the condition, but they also foster as much of a connection as possible between the world of their dementia residents and the larger world of the nursing home.

Obviously, running a dementia unit will present constant challenges, but Wilson sees only positives in the way the program has developed so far and is proud of the philosophy of her program.

“When working with people with dementia, we’re not necessarily focused on the end product,” she said. “It’s about taking their daily activities, engaging them in the process and creating moments of joy and acceptance throughout their day. If somebody wants to sit and watch people, then they should be able to have that activity be a comfortable and pleasant experience.”