Management Issues in Primary Care The Ideal Alzheimer Home

The number of Alzheimer homes is likely to multiply over the next decade, given the massive increase in patients being predicted. In addition to the well-tried prosthetic approach, an Alzheimer home should ideally contain three components: healing architecture, a more humanized approach to human-resource management, and leading-edge electronic surveillance and artificial intelligence.

By Bernard Viau, BA, MA, Fellow CSI

ew terms are being used these After several trials, the ideal number unit at Saint Brigid’s Home7 in Ndays to describe the care of the of patients per unit has been set at Sillery, Carpe Diem8 and Jean XXIII elderly: person-focused care, a pros- nine during the day and 36 at night. in Trois Rivières, Mémoire du Coeur9 thetic approach, proximology, med- Surveillance is provided by silent in Joliette, and Fleur-Ange10 in Hull. icalized residences with a human alarms that are activated at the nurses’ In the last four years other Alzheimer dimension, and even care re-engi- station (e.g., if a patient gets out of homes were built. In 2005 in neering. These words indicate a true bed). Food is prepared daily in each Longueuil and Sherbrooke and in desire to do better and change the unit, because odors are important in 2007 the Francesco Bellini Home in structure of the care provided at the managing the disease. Each unit also Laval, the Pavillon des Bâtisseurs in end of a person's life, even though has its own enclosed garden and Montréal and the Maison Alzheimer the actual introduction of this philos- some animals as well (zootherapy). de la Rive-Sud. taking their inspira- ophy remains to be clarified.1 The use of chemical tranquilizers is tion from their forerunners (the Under the public health system, generally discontinued after one Pavillon des Bâtisseurs in Montreal extended-care centres often group month for most residents and the cen- and the Maison Alzheimer de la Rive- Alzheimer patients on specific floors tre has never used physical restraints. Sud). Quebec has also completed the behind locked doors. This is obvious- Another notable point is that there construction of a specialized research ly one solution, but there are better. have been no cases of employee burn- facility, the Alzheimer-Vilar Centre, The first home specifically designed out since the centre opened. which has been based on other for Alzheimer patients was the The design of Alzheimer homes European centres.11 ADARDS centre2 which opened in improved over the following years, The principle behind all of the 1991. The centre is configured in the and other homes were soon created in above-mentioned Alzheimer resi- form of a cross with four separate various countries. Today, there are dences is to group a dozen patients self-contained “houses” during the many Alzheimer homes in the United into semi-family units. This pros- day. At night, through the use of cam- States. Most of them are managed by thetic approach makes the best use ouflaged doors, the complex converts private interests, like the six of residents' present and residual into four wings of a single unit, with Alzheimer houses of the RSL Haven abilities, rather than using the degree a central nurses’ station at its core. Group.3 In France, a physician entre- of loss as the means of classification preneur, Dr. Sotton, has now opened (which is the usual practice in Bernard Viau, BA, MA, Fellow CSI a ninth Alzheimer home (Jardins extended care centres today). It is Former Coordinator, Maison Alois d’Asclépios).4 In Canada, there are more a question of accompanying Alzheimer des Laurentides, already several models in place: the patients through the process of cog- St-Jérôme, 5 Former Editor of the Alzheimer’s Dorothy Macham Centre in Toronto, nitive diminishment, rather than section at DMOZ.org and son of a the Strathcona Alzheimer Care reminding them that they used to deceased Alzheimer mother. Center6 in Edmonton, the prosthetic feel more at ease in society in gener-

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al. This approach is, in fact, not new. adjust fairly well to a Kafka-like type We have said that architectural The first to apply the prosthetic of architecture, the same cannot be space is significant. To date, no stud- approach (caring for patients with said for children or patients who feel ies have been conducted regarding compassion), were nursing nuns. more at ease in a more intimate, invig- the importance and influence of Definite improvements have been orating space. A good example of architecture and the eventual treat- made in the architectural design of architectural adaptation in Canada is ment of Alzheimer’s disease. We do, hospitals and extended-care centres. the Hospital for Sick Children, con- however, know that a number of We now know that all space sur- structed under the direction of ancient traditions incorporated what rounding us represents an invisible Bernstein and Associates.15 The same is known as sacred geometry into force that influences the way we feel applies to the McMaster University their customs, and that there is now a and, in a way, dictates our instinctive Health Centre, with an environment branch of architecture exploring conduct. For example, what is the that makes one think of giant building healing architecture—a spatial hidden message12 that the architec- blocks. But, as the designers of these design that contributes to the tural environment (e.g., a fortress- centres have said, when dealing with improved well-being of body and like nurses' station, a spacious entry Alzheimer patients we must go fur- mind. The prestigious American hall like those found in hotels, a large ther than a style of architecture, Institute of Architects now has a sec- counter like in an after-sales service whereby medicine is delivered to the tion dedicated to this forward-look- department, a small corner office, or patients. ing concept.17 In Montreal, architect a comfortable, welcoming sitting Something special is required, Frédéric Klein has designed an inno- room) transmits to patients, families something unique. Why? An vative complex18 for McGill and employees? As such, the archi- Alzheimer patient can decide at two University’s Health Centre. It is tectural environment has a direct in the morning that he wants to go composed of various clusters of impact on our perception of others home. The word “home” in this con- units where a warm, comfortable and human relationships.13 Like chil- text denotes a profound, fundamental atmosphere enhances patients’ feel- dren, Alzheimer patients will react reality, because the word does not ings of security. Heart-shaped struc- far more intensely to this invisible refer to his previous residence but to tures form a lotus-flower configura- component of the architecture than a state of mind, a feeling of comfort tion, which is an architectural con- we would. For that reason alone, we and safety within an environment cept based on the invisible structural must create a special environment for rich with meaning. What Alzheimer component of sacred geometry. them, a space that they will be able to patients who suddenly pack their We have to rethink architectural recognize and call home. bags are really saying is that they space using orientation, volume, and find our care centres impossible to lighting to produce a special atmos- Design live in and feel they are there just phere which, according to Klein,19 Several studies have been conducted waiting to die. The word cantou makes employees feel more produc- concerning the ideal physical layout comes from the Old French language tive and patients more alive. This for Alzheimer units, considering and means a welcoming home, concept is as old as time itself for issues ranging from doorknobs to the where safety and comfort reign. Such practitioners of Chinese Feng Shui most attractive wall colours. However, things as a pleasant aroma lingering and its Vedic equivalent Sthapatya,20 most Alzheimer houses today are built throughout the house is an important but in the Western world the notion on a rectangular or, more rarely, a element to consider. Serious aro- is still relegated to the area of sci- hexagonal plan. Alternatively, they matherapy research has proved that ence fiction. There is, however, one can have a circular configuration, like this aspect should be carefully con- ray of light: the Canadian Le Cantou14 in Switzerland and sidered because olfactory memories Government has for some years Mémoire du Coeur in Joliette, last far longer than the patient’s other been subsidizing research into the Quebec. While a healthy adult may types of memory.16 impact of architecture on health.21

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Development Jardins d’Asclépios in the French the general public regarding the pro- Planning the ideal Alzheimer home Jura. The prosthetic approach is def- tection of privacy, and rightly so, but should take three essential compo- initely the one to be preferred, the use of these same technologies in nents into account: healing architec- because it has proven its worth. the context of an Alzheimer home ture, more human resource manage- However, if the board of directors could only have a positive impact on ment and artificial intelligence appli- does not provide decent salary con- patients’ quality of life as they near cations. The first would be architec- ditions for employees (without the end of their lives. ture based on sacred geometry, which there will be a constant The philosophy of the Alzheimer’s because this could reduce stress, turnover), all of the lip service paid Movement states that the person enhance a feeling of safety. and result to the patient-focused approach affected maintains an intense emo- in a marked improvement in the becomes a barefaced fabrication. tional relationship with those around quality of life of patients, employees, The third component of the ideal him, and needs stimulation appropri- and families. Only too often, when Alzheimer’s home should be the ate to his potential and his need for planning an extended-care centre, we extensive use of surveillance technol- feelings of self-worth and safety.29 are content to calculate square ogy and artificial intelligence to That’s all very well, but what actually footage, sinks and toilets. It may now improve care and patient manage- happens in real life? When planning be time to ask ourselves questions ment. The market potential for this an Alzheimer home, care must be about another approach to the archi- cutting-edge industry is enormous. taken not to pay attention solely to its tectural space surrounding us—an Several technologies are now avail- cost-effectiveness, consequently leav- essential yet invisible component. able, ranging from intelligent cloth- ing the human aspect and patient The second most important ele- ing to muscle-movement detectors in approach behind. It would be prefer- ment to be incorporated into the hospital beds,22 together with radio- able to plan and budget based on the ideal Alzheimer home would be frequency microchips (RFID)23 and cost of the three components men- human-resource management based automated thinking robots.24 The tioned above from the very start. The on respect for the individual. Many Emfit Corporation25 in Finland has extensive use of technology would public and private extended-care equipped several Finnish Alzheimer allow us to better train and better pay centres, even though luxurious, are homes with a number of its products the most important link in an staffed by poorly paid, insufficiently that help control wandering, acci- Alzheimer home: the employees. In trained, overworked employees. The dents and human error. The In Touch addition, specialized artificial intelli- public system operates in this way Health Company26 is pioneering gence interfacing with patients could because of savings achieved; the pri- remote presence technology, similar probably help reduce the depression vate system because of profits to remote-control computer pro- that, according to certain studies, gained. This ignores the fact that grams. Its newest addition is a robot affects 80% of seniors in the homes or Alzheimer’s patients, who are more companion for seniors. Intel’s “virtual waiting rooms for death” that emotional, very quickly become Proactive Health Research Center27 residences represent today. attached to their caregivers and and the Robotics Department of There is little doubt that adjust poorly to changes in person- Mitsubishi Heavy Industries28 are Alzheimer homes will multiply rap- nel. Human-resource management working on artificial intelligence pro- idly over the next few years. in an Alzheimer home must there- totypes to make the interface between Therefore, the concept must be fore ensure that there is no (or very computer and patient more user- refined right now, incorporating a little) turnover in staff. “All employ- friendly. Their goal is to be able to proven prosthetic approach, healing ees must be trained to avoid impos- interact with patients and thus allevi- architecture, human-resource man- ing the slightest constraint on ate their feelings of isolation, fear and agement based on respect, and arti- patients. That is one of the keys to boredom. The mention of surveil- ficial intelligence adapted to geron- success in this method,” states Dr. lance systems and avant-garde tech- tology. Who, in Canada, will stand Parmentier, the initiator of the nologies like RFID raises concern in as the pioneer for this field?

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References: 1. Epp TD. Person-centred care: a vision to 13. Calkins MP, Marsden JP. Home is where 23. Medical RFID tagging could save lives. be refined. The Canadian Alzheimer the heart is: designing to recreate home. Available at: http://www.online-ambu- Disease Review 2003; 5:14-17. Alzheimer Care Quarterly 2000; 1(1):8-16. lance.com/articles/doc/13/grp/Senior/pg/1/ 2. ADARDS Centre, Australia. Available at: 14. “Le Cantou.” Cantou Saint George, art/Medical_RFID.htm. Verichip http://www.adardsnursinghome.com.au/ Maison de retraite en Normandie. Corporation. Available at: 3. Resources for Senior Living, the Haven Available at: http://perso.wanadoo.fr/can- http://www.4verichip.com/applica- Groups. Available at: http://www.rsl- tou.saintgeorges/Le_cantou.htm. tions.htm al.com/. 15. “Elder Care.” Bernstein & Associates, 24. Martha Pollack, a professor in the 4. “Salins-les-Bains: bientôt la maison Architects. Available at: University of Michigan Electrical Alzheimer.” Archives de la Voix du Jura. http://www.bernarch.com/ElderCare.htm Engineering Department, has devel- Available at: http://www.voixdujura.fr 16. “La Aromaterapia.” Fundación oped an alarm, called the Auto-minder, /archives/voir_archive.asp?archive=992& Alzheimer España. Available at: that can recognize when a person is dossier=&chronologie=oui&page=67. http://www.fundacionalzheimeresp.org/ eating and remind them to take their 5. “Dorothy Macham Home.” Sunnybrook debate/aromaterapia.php medication. available at: http://www. Health Sciences Centre. Available at: 17. “Healthcare architecture.” The spacedaily.com/news/robot-04h.html http://www.sunnybrook.ca/programs/ne American Institute of Architects. 25. Emfit Corporation, Helsinki, Finland, urosciences/dorothymachamhome. Available at: http://www.aia.org research and article. Available at: 6. “Strathcona Alzheimer Care Centre.” /aah_default http://www.emfit.com/publications The Capital Care Group. Available at: 18. Bryan Lawson. Healing architecture. 26. Articles on In Touch Health Company http://www.capitalcare.net/Centres Architectural Review. March 2002. research. Available at: http://www. /sacc.htm. Available at: intouch-health.com/articles.html 7. “Marguerite Merette: Prendre soin dans http://findarticles.com/p/articles/mi_m35 27. Deshman E, Carrillo Maria C. Perspective un centre de soins de longue durée.” 75/is_1261_211/ai/84670328. Frederic on everyday techniques for alzheimer’s Unité prothétique, St-Brigid’s Home, Klein. Senior architect, Regis Cote care: research Findings, directions and Quebec. Available at: http://webperso. Association, Montreal. challenges. Alzheeimer’s and Dementia, mediom.qc.ca/~merette/brigid.html. 19. Klein Thibodeau Henderson. Volume 3, Issue 3, July 2007, pg 227-34. 8. “Maison Carpe Diem.” Société Architecture and Design, Well-being is a 28.The Wakamaru robot has been specifi- Alzheimer de la Mauricie. Available at: function of spatial energ. Available at: cally developed to simulate a human http://www.alzmauricie.org/carpe.htm. http://www.hermanmiller.com/CDA/SSA companion. It has already proved its 9. “Maison Mémoire du Coeur.” Available /CaseStudies/0,1598,a10-c78-k42,00.html worth when used with the elderly.The at:http://www.maisonmemoireducoeur.ca/ 20. Sthapatya, transcendental meditation project is sponsored by the AARP 10. “Maison Fleur-Ange.” Société Alzheimer and architecture. Available at: http:// Global Aging Program. Available at: de l’Outaouais Québécois. Available at: www.sidhadorp.nl/sthapatya/index.html http://www.aarp.org/international/agin- http://www.saoq.org/maison_fleurange.htm 21. Medicine by Design Project, funded by gadvances/innovations/Articles/a2004- 11. Includes San Secundo Memory Clinic, CIHR#SSHR, McGill University. 09-14-homecarerobot.html Turin (source: Médéric Alzheimer Available at: http://www.arch.mcgill.ca 29. Philosophy and Common Vision, Foundation newsletter, March-April /mbd /pdf/DAWSON_project_outline_pdf. Alzheimer Movement of Quebec, 2003 and the Queen Sophia Foundation 22. Emfit, Finland. Available at: http:// Annual General Meeting 25, Nov. 2000, Alzheimer Project Complex, Madrid www.emfit.com Report of Clinical Committee written by (source: Diario Médico, Spain). Martine Lecoeur. 12. “What is your building saying?” Ideas Institute. Available at: http://www.ideas institute.org/article_021103_a.asp.

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