Tuesday, 13 November 2012

Helping dementia patients feel at home

Residents comfortable with Aussie group's care concept, Amy Khor notes
By Salma Khalik, The Straits Times, 12 Nov 2012

SHE cooks her own food, does her own laundry, watches television or potters around in the garden.

But she suffers from severe dementia and is living in a dementia care facility in Australia that has a different take on how things should be done.

Indeed, anyone who rings the front doorbell for entry into one of the three cottages at The Meadows would be hard-pressed to identify the place as catering to dementia patients.

This is because the cottages, which house 40 dementia patients, look like someone's home.

Each is shaped like a Y, with each patient having her own room with en suite facilities.

Instead of the normal nursing station, the carers gather round the central kitchen counter where they have a clear view of the whole place.

Associate Professor Andrew Cole, chief medical officer at HammondCare which runs The Meadows, said classic features of a nursing home - such as long corridors, lots of rooms, confusing lighting and echoey floors with no carpets - aggravate the condition of people with dementia.

He said: "Put all that together and the excess disability you put on top of the challenge that the patient already has, it makes the quality of their lives worse."

To keep things appearing like home, the carers also cook and clean. Residents are welcome to do their own laundry and help in the cooking - or do nothing at all.

Anyone who wants to enter the place, even staff, have to ring the doorbell. Said Prof Cole: "How would you feel in your own home if people just show up in your kitchen?"

He said dementia patients get confused if they see people appearing in their spaces unexpectedly. However, when the doorbell rings, they expect someone to come in.

The two carers per cottage do everything, from fixing meals to cleaning the place and taking care of residents.

Residents who want to help cook a meal are welcome to do so. But all the knobs for the stoves are hidden so they will not accidentally light a fire.

Heavy-duty laundry of soiled bedclothes is done outside the cottage. They are taken out through a door - which has no handle and looks like part of the wall - which staff access with their pass.

For residents, there appear to be no locked doors, something doctors say can add to the frustration in people with dementia.

Prof Cole said if a resident who wants to go to the kitchen for a snack takes a wrong turn out of her room, she will come to a door that leads to the garden.

After a stroll in the garden, she will come to another door that leads back into the building. She has not been thwarted in what she wants to do, so there is no frustration, he said.

If a resident gets worked up and wants to leave, the staff will say "Sure, let me put on a coat and we can go." Usually, after a 15-20 minute walk down the road, the resident would have worked off or forgotten her frustration and say: "Let's go home."

Prof Cole said in homes where staff will not let the residents out, and instead keep trying to tell them that the place is home, it often takes more than two hours before the patient stops wanting to go out.

He added that by letting the person go out, there is positive feedback that keeps her feeling good for the rest of the day.

This home-like environment, and allowing residents to do what they like, reduces disorientation and aggressive behaviour in patients without resorting to medication, he said.

Prof Cole added that studies have shown a 30 per cent improvement in the quality of life and behaviour of residents of The Meadows, compared to dementia patients living in hospital-style facilities.

They also live much longer - an average of three years compared to one year in old-style nursing homes.

Minister of State for Health Amy Khor said after her visit: "What struck me was the whole concept of this being a home for them. It should be somewhere that they feel comfortable in. Not an institution."

Prof Cole recalls some upset neighbours when HammondCare decided to build these cottages in a residential district in 1995.

One of the neighbours asked if he would be disturbed by "naked screaming women running around the garden".

But there have been no complaints since the place opened, largely because there is very little disturbance, he added.

How to help dying patients go home
By Salma Khalik, The Straits Times, 12 Nov 2012

A THIRD of palliative-care patients at Greenwich Hospital in Sydney are able to go home, said Dr Andrew Broadbent, director of palliative care there and a lecturer at the University of Sydney.

This is good as most people want to die at home rather than in hospital. These patients would have had their medical problem, like pain or nausea, controlled.

He said many patients come to the hospital taking 15-20 types of medicines a day. The palliative-care doctors and pharmacists reassess their medical conditions and cut the number of drugs to about seven, which makes them feel better, he added.

Before they go home, the palliative team sits down with family members to teach them what to do in emergencies, such as the patient getting a heart attack.

A week or two prior to discharge, the patients are given a "gate pass" that lets them go home for the day, to get them feeling comfortable away from the hospital.

About 10 per cent of patients do not want to leave because they are scared. Hence, the hospital offers a "trial discharge" where it will keep the hospital bed for them for three days.

The hospital also gets in touch with the patient's family doctor. These general practitioners need to agree to do home visits if necessary, and to sign the death certificate when the time comes.

Financially, house visits are not attractive since the fee of about A$55 (S$70) is generally double what the doctor would charge a patient in his clinic.

But Dr Broadbent said many GPs agree to take over the care of palliative patients, especially if they had been looking after the person before.

HammondCare, a Christian charity organisation which runs 10 levels of eldercare services, including Greenwich Hospital, also follows up, if necessary, with visits by its specialists, nurses, therapists or social workers.

Residents need to put up bonds for nursing home places
By Salma Khalik, The Straits Times, 12 Nov 2012

MINISTER of State for Health Amy Khor was in Sydney recently to attend a malaria conference and visit eldercare facilities there.

She visited HammondCare on Oct 31 and facilities run by the Australian Nursing Home Foundation (ANHF) on Nov 1.

With her on the study trip were two members of the Ageing Planning Office, which implements directives given by the Ministerial Committee on Ageing, of which Dr Khor is a member.

HammondCare, a Christian charity set up in the 1930s by Anglican archdeacon Robert Hammond, runs a whole gamut of care services for the elderly. They include a small hospital, low- and high-level nursing home care, palliative and dementia care as well as homes for independent living. They are all sited on 32ha of land called Hammondville.

The ANHF is a Chinese voluntary welfare organisation set up specifically to help older Chinese who would not be comfortable in a Western-style environment. Its services range from day care to nursing home and dementia care.

In both facilities, those who can afford to are expected to pay.

People applying for independent living or low-care nursing home places have to put up a bond of A$400,000 (S$509,000) at HammondCare and A$300,000 at ANHF. Some other places charge as much as A$1 million. There are also weekly payments for different services.

Voluntary welfare organisations (VWOs) use the money for investment or to earn interest, and the proceeds are used to run the place or to build more facilities.

The homes are allowed by the government to take a certain amount from each patient's capital each month for up to five years - even if he stays for 10 years or more. The rest of the capital is returned to him when he leaves, or to his family when he dies.

Those who cannot pay the bond are usually entitled to a government pension of A$536 to A$712, with some also eligible for other subsidies like rent assistance. About 80 per cent of that money goes to the VWO.

There is currently no bond if the person is deemed to require a high level of nursing care, but that is set to change next year.

The government also subsidises the needy, who are means tested, for services such as home care or palliative care.

As HammondCare and ANHF are charities, they can top up with charity dollars for the poor if government funding is insufficient.

Ms Ada Cheng, chief executive of ANHF, said that even with a fairly high staff-to-patient ratio, good quality food, ambience and activities, its 70-bed nursing home, which opened last year, achieved a surplus of A$500,000 in its first year.

Retired and on their own but help is at hand
By Salma Khalik, The Straits Times, 13 Nov 2012

ELDERLY Asians and Westerners appear to have different needs, based on the two "retirement village" models the Ministry of Health (MOH) team saw on its visit to eldercare facilities in Sydney last month.

The 129 units at Hammondville, built by Christian charity group HammondCare, are all terraced houses where elderly Westerners live on their own, but have help to mow the lawn and change light bulbs.

They make a one-off payment of between A$350,000 and A$500,000 (S$445,500 and S$635,900) for the house for the rest of their lives, plus A$89 a week for the basic services they require. They may use the swimming pool and rehabilitation facilities at the nearby nursing home that is run by HammondCare

The one run by the Australian Nursing Home Foundation, a Chinese not-for-profit organisation to help elderly Chinese, has 46 apartments near Sydney's Chinatown area.

Here, the focus is on companionship and shared activities. The units are self-contained apartments, each with a small kitchen, living area and bedroom.

Tenants, who must be at least 65 years old, pay A$86 a week for the place. The cost for a couple is A$131 a week.

The federal government has a Community Aged Care Package for needy elderly people to help them continue living at home. This enables them to get help to clean their homes, do the laundry, take them to the doctor or do their shopping for them.

Those who can afford it pay A$10 an hour, while poorer tenants pay as little as A$3 an hour, with the government topping up the rest of the A$20-an-hour bill.

Tenants can also use the day-care services on the ground floor, where 20-25 non-residents turn up for the day. Most join in, and get provided with morning tea, lunch and afternoon tea.

Such day care is subsidised on a means-tested basis by the government, so most non-tenants pay only A$6 a day, plus A$3 to A$5 if they need transport to and from the place. No one is denied a place if they cannot pay.

Often, they just get together to play mahjong or to chat.

Minister of State for Health Amy Khor, who led the MOH team on the study trip to Sydney, said this social network is seen as important "to prevent social isolation and depression".

She told The Straits Times that the Government wants to boost social networks for the elderly, whether they live alone or with their families.

It is doing this by having more facilities in the community. For example, while the elderly might live in their own studio apartment, there would be an activity centre within the block that provides social activities.

Days spent with friends, playing mahjong
By Salma Khalik, The Straits Times, 13 Nov 2012

WHEN Madam Lau Wai Chun's husband died six years ago, she lived on her own in Sydney. Now, the 89-year-old is a resident in the city's Lucy Chieng Aged Care Centre where she gets low-level nursing care.

She entered the home last year. She decided not to live with family members - she has four children - as they all work and she would be alone during the day. She had to provide a bond of A$300,000 (S$380,000) to get a place at the home run by the Australian Nursing Home Foundation (ANHF), a Chinese voluntary welfare organisation catering specifically to elderly Chinese.

Nursing homes providing low-level care can charge as much as A$1 million as bond. They are allowed to deduct payment from this bond, up to a maximum of A$307.50 each month, for up to 60 months. The rest of the capital, A$281,550, is returned when a person leaves the home; in the event of death, it is returned to the person's family. Interest on the bond goes to the home.

Those who do not have the capital to pay the bond can instead pay the interest that would have accrued, up to a cap of 9.02 per cent per year, plus the monthly $307.50.

If Madam Lau had chosen this, she would have had to pay A$2,562.50 a month for the first five years, followed by A$2,255 a month thereafter.

Staying at the home, Madam Lau has friends to chat or play mahjong with. She said in Cantonese: "I'm very happy here. Both the food and accommodation are good. It's easy to pass the time."

Apart from the comforts of eating Chinese food and watching Chinese shows on TV, there are also activities, such as one where residents painted pots and planted flowers in them. Her family members take turns visiting after work, and take her to church on Sundays.

The home caters to people who need low and high levels of nursing care. It has a 15-bed dementia ward, where everyone has a room with attached bathroom and toilet.

Ms Ada Cheng, chief executive of the ANHF, said the home has 70 residents now and a waiting list of 160. Residents are in their 80s or 90s and many are expected to live 10 to 15 years at the home.

The Lucy Chieng home is in a residential area but has not had a single complaint in the two years since it opened.

It has a garden for dementia patients that comes with a unique "bus stop". When a dementia patient gets upset and wants to leave, no one stops him. After waiting some time for a bus that will never come, he is no longer upset and forgets that he wanted to leave.

Ms Cheng said there are plans to provide day care for up to 15 elderly people. They can come one or more days a week to socialise with others and to give their carers some respite.

Before the Lucy Chieng centre opened, she sent fliers and held an open house for neighbours, to explain what they were doing. On opening day, the centre held a fete in a nearby park and the neighbours were invited.

The ANHF has a dementia facility called So Wai in Sydney that is tight on space. There, the architect used sandstone walls to make the small garden appear bigger, while providing nooks for privacy.

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