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<<Activities for each patient are tailored based on his or her individual personality, preferences, and cognitive abilities.>>
For many patients, staying in a hospital can be stressful. It can be even more challenging for those with dementia as unfamiliar environments may trigger disorientation and distress.
To help patients with dementia adjust better during their hospital stay while recovering from their medical conditions, the multidisciplinary geriatric team at Changi General Hospital (CGH) has adopted a person-centred care (PCC) model in its dementia ward.
Located within the Integrated Building of CGH, the 20-bedded dementia ward sees about 580 patients every year.
A holistic and individualised care approach, the PCC model takes into account not just the patients’ physical recovery and needs, but also their psychosocial needs. This involves getting insights from caregivers into each patient’s regular daily routine, personality, dietary preferences, previous occupations, hobbies, faith, and things that may evoke emotional responses.
Associate Professor Lim Si Ching, Senior Consultant, Department of Geriatric Medicine, CGH, who introduced the PCC model in 2015 for elderly patients with behavioural symptoms of dementia, said that the care needs of patients with dementia are higher, with routine tasks and communication requiring more time and patience.
For example, in a general ward, patients’ mealtime usually lasts about 45 minutes but this can go beyond an hour in the dementia ward.
Recounting the team’s recent encounter with an elderly patient who took two hours to finish half a bowl of porridge, Prof Lim said, “One of the care assistants accompanied the patient until she finished her meal. Why do we do this? We believe that care and compassion are part of the treatment to help patients get better.
“Ultimately, this model of care revolves around unconditional acceptance and care of the patient.”
Prof Lim said studies have shown that the PCC model — first introduced by psychologist Tom Kitwood in United Kingdom in the 1990s — can be an effective way of managing behavioural and psychological symptoms of dementia.
Findings of a recent survey conducted by CGH indicated that the initiative has improved patient outcomes and well-being in areas such as sleep duration, meal intake, mood, and agitation level. At least 62 per cent of the ward’s elderly in-patients showed a positive increase in appetite.
Caregivers who took part in the survey also reported observing similar improvements in their loved ones’ mood and engagement level.
The dementia ward has consistently scored the most commendations from patients’ families and caregivers for every domain in CGH’s patient feedback data since 2018.
For its efforts to improve patient care, CGH’s geriatric care team clinched the ‘Dare to Do’ award at the Public Sector Transformation Awards 2020. The award recognises the spirit of risk-taking and perseverance in the public sector.
Alzheimer’s disease is the most common type of dementia, which affects around one in 10 adults aged 60 and above, and more than half of seniors over 85 in Singapore. The condition is incurable, although treatment can slow down its progression.
Some patients with dementia may exhibit difficult-to-manage behavioural symptoms, such as aggression and agitation. Other symptoms include restlessness, biting, scratching, shouting, anxiety, and depression.
Prof Lim pointed out that there are often underlying reasons for behavioural symptoms in dementia patients, many of whom can no longer use words to clearly express their needs.
“The first thing we tell ourselves when the patient is displaying such behaviour is to view it as a breakdown in communication. The patient needs something from us, but because there is a communication failure, the message is lost in translation. It could be that the patient is tired, in pain, or has a certain routine he or she is used to. In order to provide PCC and not restrain the patients, we have to understand why the patients behave the way they do,” she said.
In CGH’s dementia ward, patients enjoy the freedom of movement with close supervision.
The use of physical or pharmacological restraints is avoided and used only as a last resort in instances when patients are at risk of endangering themselves.
“Agitated patients are never left out of sight. When necessary, we will have the patient sit in a geriatric chair near to the nurses’ counter,” Prof Lim said.
While the PCC approach requires more time and commitment from the ground staff, Mdm Sinnatamby Savithri, Senior Nurse Manager at the dementia ward, said that the care team at the ward has worked together to implement this care model to manage patients in a restraint-free environment. The team meets regularly to discuss care plans and goals for each patient.
<<(From left to right) Senior Nurse Manager Sinnatamby Savithri, Associate Professor Lim Si Ching, Assistant Director Ong Siew Yit, Nurse Clinician Anna Liza Pada Bantilan.>>
“When the patients first arrive, the nurses try to find out more about them as individuals — for example, how they want to be addressed, their preferred language for communication, their past occupations, and whether they have certain memories that may trigger unhappiness. These details and their cognitive abilities are taken into account when we tailor activities to keep them meaningfully occupied,” Mdm Savithri said.
During their stay in the ward, patients may engage in music therapy, art and craft, simulation therapy, or even interact with a robotic pet as part of their therapy sessions, depending on their preferences.
There is a corner dedicated to paraphernalia, such as games, an old sewing machine, and other knick-knacks that help jog memories.
A sensory ‘tree’ filled with various everyday items like tangerines and spice sachets encourages conversations among patients.
Feels like home
The layout of CGH’s dementia ward is designed with patient safety in mind. To simulate a calming and reassuring homelike environment, corridors are fitted with grab bars to enable patients to walk safely and more confidently. Doors are plastered with wallpaper to prevent patients from mistakenly wandering out of the ward. The nurses’ station is also located nearer to the beds, allowing the staff to keep a closer watch on the patients.
Social interaction among patients and their family members is also encouraged. There is a communal dining area, where patients can gather at meal times, although these activities have been temporarily halted due to the COVID-19 pandemic.
Patients can also choose to have their breakfast while seated at a breezy balcony.
Mdm Savithri said that patients sleep better after socialising and participating in afternoon activities or therapy. In a survey conducted by the team, more than 90 per cent of the patients slept for seven to nine hours on days when they had therapy, compared to 44 per cent on days without therapy.
The nurses also provide education and counselling for caregivers so that the latter can learn to manage their loved ones’ behavioural symptoms and keep them meaningfully occupied even after they are discharged from the hospital.
There are plans to gradually implement the PCC care model across other wards in CGH’s Integrated Building.
“Besides patients with dementia, the PCC model of care is suitable for patients with developmental and intellectual abnormalities, and to some extent, patients with psychiatric issues, too,” said Prof Lim.