In this issue we have asked Anne Thomas and Ann Wyatt
to address the following question:

Which is preferable for nursing home residents with dementia —
a special care unit or integrated care?

	Anne Thomas, LMSW	Anne Thomas, LMSW, is the Vice President of Community and Specialized Programs at Schervier Nursing Care Center, a member of Bon Secours New York Health System. In her role at Schervier, Anne is responsible for the creation and ongoing operation of the Schervier Center for Alzheimer’s and Dementia Care, a unit devoted to the care of people with dementia.

The Case for Special Care Units

In my opinion, nursing facilities that make the effort to dedicate specific units or floors to special care for residents with dementia, are making a conscious decision to provide a high level of service to this population. It is a public acknowledgement of that facility’s commitment to the finest care for dementia residents and their families.

With this said, all programs need to be evaluated on their own merit.We all know of those facilities that highlight “Dementia Care” but in reality provide nothing “special.” Here are some key areas that I believe demonstrate a commitment to “special” care for people with dementia, and if implemented effectively can improve their quality of life.

Staff with the Right Stuff
People who work in dementia care and are successful have usually made a conscious choice to work with this population. Through research and anecdotal experience, we have identified core competencies for successful work with people who have dementia. The most highly credentialed professional may flounder on a dementia unit. Specialized units value the importance of the right staff and take care in recruiting the right people.

Training staff and supporting them in their difficult role is a key component of special care. Special care units require a certain amount of in-depth staff training with ongoing refreshers, case conferences and team meetings to review residents who pose challenges to the provision of optimal care.

The most well-run dementia care units recognize that the nature of the impairment requires a higher ratio of staffing. Specific personnel are assigned to the activity groups, and individualized care is provided to those who need it at any given time. In addition, approaches to care are truly multidisciplinary, with all hands on deck when it comes to interacting with and engaging residents.

Specialized programs often assign a dementia coordinator or administrative manager to oversee day-to-day operations. The best program needs constant modifications, refocusing and reenergizing. The coordinator is the program nurturer. He or she works with staff to inject energy and give the program life.

Resident Selection
In my experience, people with dementia who are integrated into non-dementia units are often ostracized. Discrimination may take place, consciously or unconsciously, making the person with dementia feel like an outsider. This individual, who is unable to make his or her needs known, or who cannot initiate activities, is destined to fail. The “problem behaviors,” which are merely attempts to communicate, become annoying to other residents, families and staff who do not understand. I find that the people who populate dementia units, including their families and the staff who work there, are more tolerant of these idiosyncratic behaviors. Thus the person feels accepted and appreciated for who they are. Their self-esteem is supported instead of being minimized.

It is human nature to want to be with people with whom we have like interests. There are varying schools of thought about separating residents into different levels of function. Most special care units pay attention to the resident mix to assure that people are with others with whom they can relate.

Programmatic Approaches
In order to determine whether the dementia care being provided is optimal, staff must take the time to discover the zone within which the person can thrive in spite of the disease. This requires a deliberate approach to daily programming that incorporates a structured routine while still being flexible. A major component of specialized care units is the structured daily activity program which provides focused meaning to the lives of the residents. Without such structure, the residents are left to flounder. We regularly witness people who are bored, restless or agitated on units where they are not provided with structured programming. Because the ability to initiate meaningful activity diminishes as the disease progresses, these residents need programs that anticipate their needs. I see special care units as the conduit to providing a meaningful life-whatever that might mean for that particular person.

Much of the programming on special care units is done in groups where the facilitators work to foster a sense of trust and community. Daily life centers around the group where friendships develop and a sense of purpose is fostered.

Family members and friends are integral members of the special care unit team. Due to the nature of the disease and additional stresses that often coincide, family support services are essential. Most special care units provide additional services such as support groups, education, “buddy systems” and counseling.

Physical Design
There has been much research in this area recommending physical design that supports and promotes positive function and decreases some of the “difficult” dementia behaviors. However, all of us have seen beautifully designed spaces where residents are disconnected and depressed. While I believe that a physical environment that has been designed to support the needs of dementia residents is a plus, design must go hand in hand with attention to programmatic approaches.

Conclusion
In conclusion, I think a strong case can be made for the use of special care units for dementia residents in nursing homes. These units provide for the residents by focusing on them as they are, providing the structured care for them and their families with the staff they need in an environment created to support their impairments and the changes they go through as the dementia progresses.

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