FRANCISCAN SERVICES CORPORATION
World War II pilot Eugene Miller, 90, flew planes long after his return to civilian life. Though he earned his livelihood as a toolmaker, his passions — which included photographing his hometown of Dayton, Ohio, as well as flying — consumed his free time.
A few years ago, Miller was diagnosed with Alzheimer's disease. As the illness progressed, he not only began forgetting details of his own life history, but also became confused and irritable. Two years ago, he became a resident of St. Leonard Franciscan Living Community in Centerville, Ohio. Like many patients with Alzheimer's disease, he can withdraw or get agitated at times. But those times are becoming less frequent, thanks to an innovative approach called the Behavior Based Ergonomics Theory (BBET) program.
The approach aims to reduce cognitive stress by customizing comforting and stimulating interventions for Alzheimer's and dementia patients. It relies on individual libraries of CDs, DVDs, games and puzzles and "memory prop boxes" to help staff and family engage and soothe patients.
"Since St. Leonard began BBET, my dad's demeanor and cognition has definitely improved," says his daughter, Fran Schlegel. "We can enjoy many of the items in his 'library' together during visits — war movies like 'Victory At Sea,' photo albums with historic pictures of Dayton, hobby magazines about airplanes. Even when he experiences mood swings, it's easier to calm him with these tools. He just seems happier — which is certainly what we want."
Though St. Leonard has recently garnered two national awards for its BBET program — a Dorland Health Silver Crown Award and a 2011 Quality Improvement Award sponsored by the American Medical Directors Association Foundation and Pfizer — such accolades were never the intention of a collaboration begun in 2008 between the senior living community and Wright State University in Dayton.
Cognitive ergonomics
"My primary interest in contacting the school was to try to get help in reducing resident falls and injuries to caregivers throughout the health care center," says Timothy Dressman, executive director at St. Leonard.
Dressman worked with Govind Bharwani, codirector of ergonomics in Wright State's college of engineering and director of nursing ergonomics at the Nursing Institute of West Central Ohio, and his daughter, independent health care consultant Meena Bharwani, to apply ergonomic principles to solve the problem.
"We found that our concepts were effective at reducing injuries in the skilled nursing areas, but not in the Alzheimer's unit," says the senior Bharwani. "We needed to try a different strategy."
Ergonomics, he explains, is the science of reducing stress. Principles of physical ergonomics — the study of fit between
people and their technological tools and environments — positively impacted the rate of accidents with most of St. Leonard's patient population. But to reduce bodily harm in patients with dementia, Bharwani had to apply his knowledge of cognitive ergonomics — the mental processes, perception, memory, reasoning and motor responses that affect interactions.
"Moderately affected Alzheimer's patients are ambulatory — and they tend to wander, making them prone to falls. We realized we had to have some sort of comforting and stimulating therapies to reduce mental stress," says Bharwani.
Adds Meena Bharwani: "The two main causes of behavior problems in Alzheimer's and dementia patients are boredom and disengagement. While most quality programs try to address these issues with various group activities, such structure is not effective for all patients and is not available 24/7. We determined that we needed to come up with a way to provide individualized interventions whenever necessary."
Calm in a box
To that end, the duo developed a resource center for caregivers that provides them with the tools required to meet the needs of each resident according to individual learning style, personality and behavior profile and cognitive skill level. Its wide array of music and video selections, as well as the games, puzzles and memory prop boxes — each carefully coded for individual BBET action plans — allows staff and family members to engage residents and reduce agitation within a few minutes.
"Organization and tailor-made selections are key to the program," says Bharwani.
The prop boxes are invaluable aids as well, says Meena Bharwani. "They contain special items from a resident's past that are furnished by family members — photo albums, magazines, stuffed animals, even small bags of money. All these things can give comfort during stressful times," she explains.
Since the program began in February 2010, results have been overwhelmingly positive. Within six months, resident falls were reduced 35 percent and the use of antianxiety medication was reduced
70 percent. "We expect those numbers to continue to decline as staff implementation of the program improves," says Bharwani.
One-on-one time
The staff is extremely receptive to the program, adds Meena Bharwani.
"They want to provide emotional care as well as clinical care," she says.
To keep nurses and aides enthusiastic about BBET, the Bharwanis set up voluntary "empowerment roles" for them after initial training. These include a coordinator to certify new staffers in BBET, a customer coordinator to help develop profiles for new residents, an education coordinator to expand the unit's Alzheimer's training library, a data coordinator to tabulate interventions with residents, and an inventory coordinator to keep the resource center fully supplied.
"My favorite part of the program is being able to delve into a patient's personality and past to help them talk about their lives," says Mary Keefer, a nurse's aide. "It's wonderful to watch the increased interaction between residents as well — they share puzzles and scrapbooks. The whole atmosphere of the unit is more relaxed and fun."
"One of the goals we have is to give the most one-on-one time with our residents and to use the least amount of behavioral medicine we can," says Terri Walker, nurse manager of the Alzheimer's unit. "This program helps residents enjoy what they know and love from their past. It helps caregivers prevent agitated behaviors by quickly being able to find items with which to engage residents. And it helps family members to have more successful visits with their relatives because they can share activities more easily."
Results have been so encouraging that St. Leonard already has expanded the BBET program to its adult day services and is planning to implement it in assisted care as well. The Bharwanis also are working on packaging the concept as a home kit for caregivers. And Wright State University and the Nursing Institute of West Central Ohio are launching a study to see if BBET can impact the actual rate of decline in Alzheimer's patients.
It's an area of great interest throughout the U.S.; according to the National Institute on Aging, experts estimate up to 5.1 million Americans may have Alzheimer's disease. The Alzheimer's Association predicts that number may reach 16 million by 2050, when the last baby boomers turn 90.
As news about the BBET program spreads, it is attracting national attention from other senior care communities. across the country. "I'm excited that St. Leonard is a pioneer in this personalized approach for Alzheimer's care, which aligns well with our commitment to person-centered care," says Dressman. "Part of our mission statement is to try to keep people as independent as we can for as long as possible. We believe our residents are enjoying an enhanced quality of life through this program."
St. Leonard is in the midst of a $30 million expansion that includes adding 30 new nursing dementia beds and 30 new assisted living dementia apartments, Dressman adds. "BBET will definitely continue to play a part in our future development," he says.
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