Older Adults with Alzheimer’s disease who are Resident of Dementia Special Care Units – Special Population Paper
1.0 Problem Statement
In today’s society, there are so many populations that can be studied. I have searched several databases to learn about different populations and decided to take a deeper look into the elderly with Alzheimer’s disease. I want to consider those older adults with Alzheimer’s disease residing in dementia special care units. A special care unit (SCU) is a facility with physicians and nurses on staff. It could be a wing or a hallway inside a nursing home or a program provided by a nursing home for residents with special needs disease or condition such as Alzheimer’s disease or other dementias. The concept of special care unit is relatively new in the field of long term care. Thereby, licensure, certification standards and current care are aspects which rely on the judgment of the families of older adults suffering from Alzheimer’s disease (Gruneir et al, 2008).
One of the major problems of SCUs is the levels of care with respect to the needs of the residents aside from other dilemmas including limited space and the basis of prioritization is need. Since special care units are intended to response to the perceived problems in the care in the nursing homes, high degrees of quality and better care are expected. The concerns of the families of residents range from regulation, administration, coordination, planning and training as well as the extent of involvement of families, relatives and friends in the activities (Sidell, 1998). Nonetheless, there are also complaints about the insufficient attention to the rights of the Alzheimer’s disease patients, lack of well-trained and motivated staffs, lack of choice of activities, overuse and misuse of physical restraints and lack of interaction between the residents themselves and the residents and the staffs, all of which contributes to the quality of care and quality of life of the patients.
These problems in the Alzheimer’s/dementia special care units impose many negative consequences not juts for the residents but also to the families and the carers and nursing staff who directly and indirectly interact with them. The fact that the difficulty in determining effects of an individual’s Alzheimer disease or condition and the affects of the inappropriate care prevails. Such situation tends to exacerbate the conditions of the Alzheimer’s patients. Poor quality care in SCUs could lead to excessive disabilities, reduction of physical safety and reduction of access to SCU services thereby poor quality of life. Many families of Alzheimer’s disease patients already feel guilty in putting a family member in SCUs and will specifically feel more anxious to learn that their family member is receiving inadequate or poor quality care. Uncertainties about their role in SCU programs and how they could contribute in sustaining the quality of life of their family members also add to their anxiousness (United State Congress, 1992). For SCU staffs, failure to effectively manage patients with behavioural disorders often results in stress, low morale and burnt out.
2.0 Literature Review
At the time when specialized caring units were conceptualized, studies are central to the comparisons of differences dementia SCUs to non-SCUs. In a cross-sectional study conducted by Grant, Kane and Stark (1995), unit and facility characteristics are the focus, and measured by means of specialized dementia care practices and organizational characteristics. The researchers found out that 18% of SCUs offer more dementia-specific features. Even so, the designation of SCU did not automatically translate into richer or more tailored services for dementia compared with units without the designation. Those facilities with designated SCUs are more likely to be rural, larger and divided into more units, have a higher proportion of residents with dementia, and have fewer residents at higher levels of acuity. Grant, Kane and Starf concluded that the presence of an SCU in a facility may be related to care of dementia in the rest of the nursing home in complex ways and that some dementia-specific features were less likely to be found in regular units of nursing homes with designated SCUs.
Buchanan et al (2005) conducted a study comparing 11, 311 Alzheimer’s SCU residents with 49, 627 Alzheimer’s disease patients. Their study revealed that SCU residents were more likely to receiveintervention programs for mood, behavior, orcognitive loss. Further, Buchanan et al discovered that CU residents were significantly more likely to be male, younger,white, married, and self pay; were significantly more likely to have poorer cognitive function and communication skills and weresignificantly more likely to receive daily anti-psychotic, anti-anxiety, or anti-depressant medications. The study implicates that SCU residents and non-residents represent distinct nursing home populations.
As Donovan and Dupuis (2000) put it, specialized care units (SCUs) for nursing home residents with dementia are increasingly prevalent. Expectedly, SCUs shall promote positive resident outcomes despite the fact that specific characteristics of SCUs most likely to yield these outcomes have not yet been identified. The authors that investigated the perceptions of family members and staff about SCU characteristics that contributes to positive outcomes for residents with dementia. Donovan and Dupuis exposed that from the family and staff members’ perspectives SCU must foster feelings of personal space, personhood, and an unforced routine. On the other end, there are serious deliberations whether dementia special care unit really improved the quality of nursing homes. A study conducted by Gruneir et al (2008) revealed that within nursing homes with SCUs, the use of physical restraints declined, the use of antipsychotics increased, andother measures remained relatively constant due to emphasis and underlying approach to care.
The design of supportive care for people with Alzheimer’s disease and related dementias in residential care has been, and still, one of the most challenging issues that researchers, policymakers, and facility administrators face. In order for these stakeholders to gain knowledge of the types of special care offered by adult care residences and assisted living facilities, there is the necessity to examine facilities with SCUs and special programs (SPs). According to Cotter et al (2003), these actions could be carried out by means of scrutinizing the organizational characteristics of facilities that offer special care, the characteristics of existing SCUs and SPs, and the opinions of owners/operators on the elements needed for establishing these units and programs. They also contend that these facilities especially SCUs must focus on the improvements needed within special care and the implications of the views of owners/operators about special care.
Organizational characteristics, most particularly, are discovered to be one of the significant contributors that affect the quality of life of Alzheimer’s patients in SCUs. Hoffman (1998) contends that the10 most frequently reported problems in order of prevalencewere: inadequate staffing, lack of staff training, inadequateprogramming for residents, poor physical environment/design,lack of support from facility staff inadequate funding, lackof support from administration, excessive staff turnover, conflictwith families, and inadequate admission criteria. How these elements impact the quality of SCU programs hence the necessity for creative strategies and meaningful interventions.
Wood et al (2005) ascertained that routine activity situations may act as potent environmental influenceson the quality of life of people with Alzheimer’s disease. The finding is based on the conducted structured observation in four consecutive days, from eight in the morning until eight in the evening. The study aimed to examine the residents’ social and physical environmental interactions time use and apparent affect. Prevailing activity situations and corresponding behaviors and affects were recorded. Meals/snacks and someactivity groups were positively associated with use of physicalobjects and engagement in activities. However, residents were predominantlyenvironmentally disengaged, inactive, or without positive affectsduring the most prevalent activity situations of backgroundmedia, downtime, and television.
For Kovach and Henschel (1996), SCUs activities must focus on therapy as it can prevent behaviour problems, relieve boredom, and to maintain or restore holistic health and function. Alzheimer’s disease patients are spending more time actively participating in an activity when they were able to make a cognitive tie between the current activity and an event from their past through reminiscing. Active participation in therapeutic activities was associated with increased daytime napping but was not related to continuous sleep at night. This is because residents of SCUs differ in level ofcognitive impairment, in behavior, and in functional and physical status (Holmes et al, 1990).
Soto et al (2008) also describe the cognitive, functional, and nutritional features of patients admitted to an SACU for elderly patients with Alzheimer’s disease. Through a one-year observational study of patients with AD and other related disorders, a comprehensive neurocognitive and non-cognitive geriatric assessment was performed to 492 patients. The authors found out that 80% of patients had probable Alzheimer’s disease or mixed dementia, less than 20% had other causes of dementia. Soto et al also noted that gait or balance disturbances and unsatisfactory nutritional status is common in SCUs. Soto and his colleagues concluded that Alzheimer’s disease complications are also reasons for admission in SCUs therefore the need to determine the clinical characteristics of Alzheimer’s patient with emphasis on their complications.
A descriptive study conducted by Gibson et al (2004) explores the advantages of environment to Alzheimer’s patient in a secured dementia care unit. The study involved a convenience sample of 19 residents who were relocated to the unit completed a performance-basedorientation task and a structured interview and tests of psychologicalfunction(cognition, depression, and visual-spatial ability). Eighty-four percent of the residents were able to perform their orientation task while others required signs and symbols prior to performing a task. There are also 38% who are intruded while performing a task mainly because of the need to seek social interaction. The authors concluded that the results of the study attest to the importanceof understanding the multiple factors that determine environmentaluse for Alzheimer’s disease patients and with greater weight given to the design of special care units.
Morgan et al (2004) maintain that there is limited information bout the capacity of rural nursing homes to provide specialized dementia services despite the fact that one in four seniors currently lives in the rural area. Further, the authors also believed that the physical and social environments are increasingly recognized as important factors in the quality of life and functional ability of persons with dementia. In their comparative study, eight rural nursing homes are compared with to eight same-sized rural nursing homes that did not have SCUs. Morgan et al (2004) found out that SCUs were more supportive on six dimensions: maximizing awareness and orientation, maximizing safety and security, regulation of stimulation, quality of stimulation, opportunities for personal control, and continuity of the self.
The first intervention is central on the process of choosing the best special care units for the person with Alzheimer’s disease or related dementia. Guides to long term care facilities are produced and disseminated to the families, relatives, friends and other relevant stakeholders who intend to place the patient in specialized facilities. For instance, Virginia Department for the Aging released a booklet/guide. The guide stipulated the steps to take in finding the best SCU: visiting more than a single unit, determining the resident-to-staff ratio, accomplishing written documents and coordinating with more SCUs. As such, gathering some basic information about the SCU that best suits the needs of the Alzheimer’s patients must be a priority to ensure the credibility of the SCUs.
Visiting several facilities could allow the families of the patients to compare one with another and to better understand the kinds of services in specialized care for patients with Alzheimer’s disease and related dementias. Two most important things to note are: the overall atmosphere of the unit and how staff interacts with residents. Further, the staff levels highly depend on the needs of the residents in the facility. The ideal ratio is four to six residents to one staff person. Next, written description of the services and the programs offered by SCUs as well as the charges or fees associated with those services is the things that the family must seek. Other things that the family should be aware of are:
- Clear explanation of how the special care unit differs from the rest of the nursing home or assisted living facility;
- Description of the physical environment in the special care unit:
- Description of any specialized training the unit staff has received;
- Statement of the resident-to-staff ratio for each shift in the unit; and
- Description of the level of personal care that your relative or loved one will receive.
There are also specific aspects that the family must ask prior to placing the demented patients in residential care structures. Questions to ask shall focus on philosophy, care plan, staff members, physical environment, activities and programs and use of restraints.
1. Is the philosophy and mission of the special care unit stated in the written description of the unit?
2. Does the mission or goal of the unit (or specialized program) clearly state the benefits that your relative or loved one will receive if they are placed there? Can the unit staff tell you what is special about the care offered in the unit?
3. Do the other residents in the special care unit have capabilities similar to that of your relative or loved one?
4. Does the special care unit recognize and respect religious, ethnic and cultural considerations consistent with your loved one’s background or beliefs?
5. Are advance health care directives (such as a durable health care power-of-attorney and a living will) reviewed and honored by the staff of the special care unit?
6. What are the unit’s policies regarding entry and exit from the unit?
7. Will changes in your loved one’s condition or abilities cause them to become ineligible to be in the special care unit?
8. Does the special care unit accept individuals who have late-stage dementia and/or a debilitating illness?
9. Will the special care unit include you when developing and/or reviewing a care plan that is customized to meet the needs of your loved one?
10. Will staff members with different skills (nurses, social workers, aides, etc.) work together as a team to develop the care plan?
11. Will the staff meet regularly to update the plan and make changes if necessary to meet your loved one’s changing needs?
12. Will you be notified when changes are made to your loved one’s care plan?
13. What are the unit’s practices for addressing disruptive or difficult behavior in its residents?
14. Is the number of staff members on duty adequate to meet the needs of the unit’s residents? Is the staff-to-resident ratio significantly better in the special care unit than in the rest of the nursing home or facility?
15. Does the special care unit’s staffing plan allow for continuity of care by having the same staff members assigned to the same residents?
16. Is dementia-specific training required for all staff members of the special care unit?
17. Do staff members have the opportunity to attend workshops or training sessions to maintain or increase their skills?
18. Do you feel comfortable with the staff members and confident in their abilities?
19. Is there a central or convenient living area where residents can interact with each other under the supervision of the staff?
20. Does the special care unit provide adequate safeguards to keep residents from wandering away?
21. Is the special care unit bright and cheerful? Does it have both natural sunlight and plenty of artificial lighting to keep the surroundings bright?
22. Does the special care unit provide opportunities for residents to engage in safe and secure exercise both inside and outside of the facility?
23. Are chairs arranged in the special care unit in ways that encourage the residents to interact with each other?
24. Does the special care unit have facilities and equipment to support familiar activities for residents like cooking, cleaning and gardening?
25. Does the special care unit encourage residents to bring furniture and other personal items from their homes for use in their rooms?
26. Is the environment in the unit calm and pleasurable?
Activities & Programs
27. Does the special care unit have an established routine that is consistent on a daily basis?
28. Does the unit offer varied activities for residents every day of the week? How do these activities differ from the activities offered to residents in the rest of the facility?
29. Does the unit offer some activities at night for residents who are unable to sleep?
30. Does the special care unit use various therapies (art therapy, music therapy, movement and exercise therapy, etc.) to involve and motivate its residents?
31. Are individual hobbies and interests accommodated and encouraged?
32. Are the current residents active and engaged in activities?
Use of Restraints
33. Does the special care unit use physical or chemical restraints?
34. If the unit uses restraints, under what conditions do they use them, and for how long?
35. Is a resident’s family notified when restraints are used?
Alzheimer’s disease and other demented patients are surviving longer than they did 30 years ago because carers continued to search for innovative solutions to the management and treatment of the disorders and its behavioural manifestations. Sommer and Ross (as cited Doyle, 1992) reported that changing the physical environment of the patients is beneficial in two ways. A more inviting place encourages Alzheimer’s disease patients to interact socially while also restoring their competent performance. The role of the environment is to compensate for disabilities and not to modify them therefore the requirement to create a situation by which minimal restraint is needed to assure patient safety. In addition, the homelike atmosphere in SCUs stimulates more appropriate behaviour. As said by Doyle (1992), designers of special care units have paid attention to the size of the unit (smaller is better), physical designs which help in spatial orientation, walking circuits which cater to wanderer behaviour and so on.
Another intervention centers resident relationships with emphasis on the role of the staff. The flexibility of staff is crucial to the success of managing residential aged care in general. While some routines are necessary to the operation of a treatment program, there needs to be as much flexibility as possible. Staffs are thereby trained to develop and utilize personal relationships skills to play a facilitating and calming role which provides a humanizing element while also permitting patients to live in a dignified way. In the nursing management, the communication skills of the staff are also honed. Bartol (1999) recommends altering style of speech, speaking slowly, clearly, increasing volume, decreasing tone and also nonverbal communication strategies. Other specific recommendations are overemphasis and exaggeration of facial expressions, standing directly in front of the patient, always maintaining eye contact, moving slowly, and not abruptly confronting the demented client from behind (Doyle, 1992).
Common activities and programs intended for Alzheimer’s patients in the SCUs include: large group activities involving either active participation such as bingo, singing or passive participation such as watching films or visiting entertainers; occupational therapy such as craft, gardening; mental activity such as reality orientation, sensory stimulation; and physical activity such as physiotherapy, walks outside (Rosewarne et al, 1991). There are, further, two most common therapies: reminisce therapy and reality orientation therapy (ROT). The former is discovered beneficial for the management of more confused elderly but the improvement in a group of confused elderly while acknowledging that the therapy was not suitable for the more severely demented. The latter therapy, on the other hand, has three major components:
1) Informal, or 24-hour, ROT involves staff presenting current information to the patient in every interaction, a commentary on what is happening and reminding the patient of the time, place and identities around them.
2) One of the innovative aspects of RO was its involvement of all grades of staff in group work.
3) The third aspect involved staff maintaining a particular attitude to each patient, according to the patient’s personality and needs including identifying the person’s mechanism of coping with their memory loss and responding appropriately.
An administrative rule in West Virginia prescribes specific standards and procedures to provide for the health, safety, and protection of the rights and dignity of individuals served by Alzheimer’s/dementia special care units and programs. The rule specifies the training that shall include at a minimum the facility’s philosophy and resident care policies; the nature, stages, and treatment of Alzheimer’s disease and related dementia; positive therapeutic interventions and activities; communication techniques; behavior management; medication management; therapeutic environmental modifications; individualized comprehensive assessments and care plans; the role of the family and their need for support; staff burnout prevention; and abuse prevention.
Another state policy that relates to my population is the Minimum Standards of Operation for Alzheimer’s Disease/Dementia Care Unit. The rule outlines staffing, assessment of individual care plans, therapeutic activities, social services, nutritional services and physical layout of dementia care units. The therapeutic activities section of the chapter, in particular, discusses how, when and under what circumstances does activities must be delivered to Alzheimer’s disease patients. Specifically, the rule suggests that activities shall tap into better long-term memory than short; provide multiple short activities to work within short attention spans; provide experience with animals, nature, and children; and provide opportunities for physical, social, and emotional outlets.
Bartol, M.A. (1979) Nonverbal communication in patients with Alzheimer’s disease. Journal of Gerontological Nursing, 5, 21-31
Buchanan, R. J., Choi, M., Wang, S., Ju, H. and Graber, D. (2005). Nursing home residents with Alzheimer’s disease in special care units compared to other residents with Alzheimer’s disease. Dementia, 4: 249-267.
Choosing a Dementia Special Care Unit. (2004). Virginia Department for the Aging. Retrieved on 14 November 2008, from http://www.vda.virginia.gov/.
Cotter, J. J., Leon, J., Akers, A. J. and Smith, W. R. (2003). Special care for persons with Alzheimer’s disease and related dementias in Virginia adult care residences. American Journal of Alzheimer’s Disease and Other Dementias, 18(2): 105-113.
Donovan, C. and Dupuis, M. (2000). Specialized Care Unit. Geriatric Nursing, 21(1): 30-33.
Gibson, M. C., MacLean, J., Borrie, M. and Geiger, J. (2004). Orientation behaviours in residents relocated to a redesigned dementia care unit. American Journal of Alzheimer’s Disease and Other Dementias, 19(1): 45-49.
Grant, L. A., Kane, R. A. and Stark, A. J. (1995). Beyond labels: nursing home care for Alzheimer’s disease in and out of special care units. Journal of American Geriatrics Society, 43(5): 569-576.
Gruneir, A., Lapane, K. L. Miller, S. C. and Mor, V. (2008). Is Dementia Special Care Really Special? A New Look at an Old Question. Journal of American Geriatrics Society, 56(2): 199-205.
Gruneir, A., Lapane, K. L.. Miller, S. C. and Mor, V. (2008). Does the Presence of a Dementia Special Care Unit Improve Nursing Home Quality? Journal of Aging and Health, 20(7): 837-854.
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Holmes, D., Teresi, A., Weiner, A., Monaco, C., Ronch, J. and Vickers, R. (1990). Impacts associated with special care units in the long term care facilities. The Gerontological Society of America, 30(2): 178-183.
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Morgan, D. G., Stewart, N. J., D’arcy, K. C. and Werezak, L. J. (2004). Evaluating rural nursing home environments: dementia special care units versus integrated facilities. Aging and Mental Health, 8(3): pp. 256-265.
Rosewarne, R., Carter, M.G., & Bruce, A. (1991) Hostel Dementia Care: Survey of programs and participants (Victoria). Report to Commonwealth Department of Community Services and Health.
Title 15 – Mississippi Department of Health, Part III – Subpart 01 (Health Facilities Licensure and Certification). Chapter 50 Minimum Standards of Operation for Alzheimer’s Disease/Dementia Care Unit. Office of Public Health. Retrieved on 8 December 2008, from http://www.msdh.state.ms.us/.
Title 64 – Legislative Rule. Series 85 Alzheimer’s/Dementia Special Care Units and Programs. Bureau of Public Health. Retrieved on 8 December 2008, from http://www.wvdhhr.org/ohflac/Dementia/64-85.aspx.
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Wood, W., Harris, S., Sniders, M. and Patchel, S. A. (2005). Activity situations on an Alzheimer’s disease special care unit and resident environmental interaction, time use and affect. American Journal of Alzheimer’s Disease and Other Dementias, 20(2): 105-118.