Dorothy Macham Home Caring for our aging verterans

A few years ago on a sunny spring day at the Dorothy Macham Home a puzzled gardener was looking at the flower beds. One of the residents was pulling up flowers from the pristine beds of soil surrounding the yard. His nurse trailed behind the patient and cheerfully replanted each flower.

The gardener asked the nurse to get the resident to stop picking the flowers. The nurse quickly responded to the gardener saying, “But it’s HIS garden!”

Smiling as she recounts the event, “It showed me how our staff really understands what we are trying to do here,” says Dr. Charles, “We want our residents to have a sense of ownership and feel like this is their home.”

The Dorothy Macham Home, part of Sunnybrook Health Sciences Centre, in Toronto, Ontario, provides nursing home and complex continuing care to 500 Veterans from the Second World War and the Korean War. Dorothy Macham Home cares specifically for Veterans with challenging behaviours due to dementia. Charles, the medical director for Veterans Care at Sunnybrook, notes that before the home was built in 2000 there was a growing number of Veterans with dementia and disruptive and/or aggressive behaviours due to dementia.

In 1997, the hospital was already planning to a build a unit specifically for Veterans with challenging behaviours, when a a fatal fire broke out at Sunnybrook. The resultant inquests and safety reviews came to the same conclusion as the hospital; a wing tailored to the specific needs of these Veterans was required.

This unfortunate incident brought new light to a gowing need and Veteran Affairs Canada generously funded the building of the unit. The home was opened in 2001, and Dr. Charles notes that there are plenty of Veterans across Canada who require a facility like this.

The prevalence of dementia increases with age, explains Dr. Charles. A history of alcohol abuse or stroke also increases a person’s probability of acquiring dementia. Second World War and Korean War Veterans are getting older and have risk factors for stroke and dementia. Therefore, there are increasing numbers of Veterans with dementia.

Not only are Veterans more likely to have dementia, Charles finds they are more likely to have aggressive behaviour. “Many of the men are trained to fight and have fought in a war. When people have dementia, they are often thinking of the past. Some of them are thinking they are still in the war,” explains Charles.

Personalized care is stressed to the staff working at the Dorothy Macham Home. They try to find the meaning behind behaviours and identify unmet needs. Every Veteran is treated uniquely according to their needs. Former night watchmen are allowed to roam the halls at night and old farmers tinker with their “tractor,” which looks an awful lot like a wheelchair, without disruption from nurses.

“We plan care around the resident’s needs,” says Charles. An important aspect of the care is flexibility so that the Veterans can eat when they are hungry, sleep when they are tired, wander around the unit and usually go outside when they want. The home has ten residents with ten different care plans based on each resident’s needs. “The idea is to make the residents feel like they have some control,” she remarks.

Dr. Charles notes that all too often patients with dementia are not able to communicate their needs and are not understood by their caregivers. The key to helping a dementia patient is getting to know the person on a deeper level. “You have to understand what is behind the outburst and what is triggering their behaviour,” she says.

The Dorothy Macham Home’s interior was built to look like a one-story house. It has ten private rooms, a common room with a fireplace, a residential kitchen that looks out into the dining room, an entertainment room, an activity room and an enclosed therapeutic garden.

Today, on my visit the Dorothy Macham Home is relatively subdued. Some Veterans sleep the day away in their beds while others make use of the wandering path, the home’s main artery in the centre of the home. One sits in front of the fireplace. Across the room, nurses busily prepare food in the kitchen, while a Veteran opens the door to get some fresh air in the garden. Sunnybrook architect, Norm Abrams, with input from Sunnybrook staff, specifically designed the home to be as safe as possible for both staff and Veterans. The home is modelled after the Alzheimer’s Disease and Related Disorders Society (ADARDS) nursing home, in Tasmania, Australia.

While the Dorothy Macham Home is very similar to the ADARDS nursing home, the main difference stems from the two countries’ climates. Tasmania’s temperatures are conducive to outdoor activity year-round and that is not the case in Canada, so Abrams had to sharpen their pencils to adapt some of ADARDS’ design.

A good example of this is the wandering path located inside the home. The path is a safe way for residents to walk around the home without travelling past other resident’s rooms. “Many people with dementia like to wander,” says Dr. Charles, “[and] many people with dementia are territorial.” A high number of conflicts would happen when residents entered each other’s rooms. The path is designed to help prevent conflict, while giving residents a safe place to go. In contrast ADARDS’ wandering path is outside. Security is also evident upon first entry. In order to reduce residents’ sense of confinement, the main door is camouflaged into the wall. Right beside the hidden door is another door that is part of the wandering path, a similar feature of the ADARDS home. “The door is as hidden and seamless as the fire code would allow us,” says Charles. “We don’t want our residents to feel trapped here. If they saw a door they might get agitated and want to leave.” All the nursing supplies next to the Veterans’ rooms are also kept hidden in hallway cupboards so that the home does not look institutional. Each of the ten rooms has two exits for staff safety while every bedroom has a sensor flooring system that detects any downward pressure. This in turn rings through to the nurses’ hand-held phone. The sensors allow nurses to intervene before a conflict if a resident wanders into another resident’s room.

Even the mirrors in the washrooms had to have door covers. “Some dementia patients don’t recognize themselves anymore,” says Charles, as they may think that their reflection is an intruder and become confused or angry.

The main nursing station is stowed away in a wood armoire in the common room. It is important to reduce excess stimuli for people with dementia notes Dr. Charles, “We try to remove the objects that might agitate them.” Making the nursing station into a homey creation helps residents feel more at ease in their surroundings.

Nurses routinely have residents sit with them while they do their work on the computer, and residents often feel that they are working with staff and helping them. Residents are even included in the day-to-day administrative activities of the home, “We let the residents sit in on rounds when we are discussing their care,” says Charles.

Dr. Charles notes that the Dorothy Macham Home operates on a ‘living model of care’ where Veterans live in the Dorothy Macham Home as long as they require the therapeutic environment of the home. . Veterans stay until it is deemed they can safely return to their previous residence. “Residents can be here anywhere from two weeks to two years,” says Charles.

During their stay, Veterans are encouraged to participate in a variety of activities to enhance their quality of life. This includes many different types of therapy such as: creative arts, recreation therapy, and, music therapy. A musical therapist comes in and sings each resident’s favourite songs one on one. A handcrafted silk quilt hangs on the wall, each square inspired by someone involved with the home. A nearly finished wall painting greets everyone who enters the activity room. The residents working on the colourful landscape of a dog on a farm were not able to complete it so it awaits new talent for completion. It’s all part of the model of care, which Charles says has been very successful.

After the home’s first full year Dr. Charles compiled a report which found: employee injuries from resident incidents were reduced by 30 per cent across the cognitive units of Sunnybrook’s Veterans unit; incidents of aggression between residents were reduced by 55%; and families of discharged veterans gave the Dorothy Macham Home a 100 per cent satisfaction rate on all 51 questions on the Family Satisfaction Survey.

The first of its kind in Canada, Dr. Charles notes that more facilities like the Dorothy Macham Home need to be built in the coming years. With the baby boomers becoming an elderly demographic, incidents of dementia are only going to become more frequent.