Covid-19 presented unique challenges for memory care providers.
These challenges included limiting the ability of residents to walk about freely and congregate with each other, and ensuring the stability of their daily routines.
Additionally, a report from the Alzheimer’s Association found that people with cognitive decline were more likely to contract Covid-19 than their healthier counterparts.
Necessity being the mother of invention, the pandemic is also bringing about new approaches to memory care treatments which, if they prove to be successful, can become part of treatment in a post-pandemic landscape.
These innovations include utilizing telehealth platforms to create baseline assessments of older adults in cognitive decline, and developing care plans in coordination with patients and their primary caregivers.
Architects and designers, meanwhile, are using Covid-19 as an opportunity to modernize built environments and incorporate changes to designs that have remained static for years. These recommendations are finding positive reception now, whereas they might have been ignored by providers in the past.
Moreover, memory care specialists are reviewing their programs for ways to improve or enhance outcomes. Frontier Management, which has a portfolio of over 120 communities including a sizable memory care footprint, launched a pilot program exploring how adjusting the sleep cycles of residents in cognitive decline can lead to improved health outcomes and a better quality of life.
Covid-19 led to huge surges in demand for technology solutions among providers, and telehealth and telemedicine platforms led the charge.
A survey conducted last year by Senior Housing News in partnership with global health technology firm Philips found that 87% of respondents expected to increase their budgets for technology solutions in 2021.
Telehealth holds promise as a tool for treatment of seniors with Alzheimer’s disease and other cognitive impairments, Dr. Jessica Zwerling, director of the Montefiore Center of Excellence for Alzheimer’s Disease at Montefiore Health System in The Bronx, New York, told SHN.
Her team adapted its “Coordinated Care At Risk/Remote Elderly” program (CCARRE) to provide collaborative telemedical care for cognitively impaired older adults and their caregivers during Covid-19. This involved starting visits via telephone to develop a baseline of trust, then progressing to video calls in which the team was able to complete real-time safety evaluations, address advance care planning and care goals, and overcome language and other cultural barriers to this vulnerable population.
Montefiore’s patients ranged from seniors living at home to residents of assisted living communities. The CCARRE team included a bilingual/bicultural social worker and a neurologist conducting the telehealth visit with a patient and the identified health care proxy or caregiver on record.
At the end of the televisit, the CCARRE team prepared a comprehensive plan of care that addressed the patient’s cognitive status and any medical, behavioral or psychosocial issues. These plans were discussed with the patient and caregiver, and reports were sent to the referring physician or primary care provider, to optimize management of comorbidities.
From March 2020 to May 2020 — the peak of positive Covid-19 cases in New York — Montefiore evaluated 85 patients as part of the program. The Montefiore team discovered that starting telemedicine visits on the phone to establish a rapport with the patient and caregiver, before asking for permission to switch to video, was more likely to break down patients’ fears of using technology to assess their conditions.
The video visits, meanwhile, offered doctors a look into patients’ homes that office visits did not, revealing physical and other safety concerns. In addition, direct conversations about social determinants of health were emphasized. The CCARRE team was able to identify patients who needed home assessments and prioritize those who needed urgent follow-up.
Zwerling believes that CCARRE and similar programs will play a role in a post-pandemic landscape, can help older adults achieve more positive health outcomes, and manage initial signs of cognitive decline earlier.
“I’m hoping it’s here to stay,” she said.
Rethinking sleep cycles
Frontier Management was exploring new approaches to memory care well before Covid-19 disrupted the industry. The Portland, Oregon-based operator’s memory care philosophy, Spark, is based on Montessori-style teaching methods intended to encourage residents’ freedom of choice and self-expression, as well as fostering and maximizing the skills they still possess.
Frontier’s newest program, Eventide, looks to maximize the sleep cycles of its memory care residents, Vice President of Operations, Midwest Region Lesley Durkan told SHN. She believes that the amount of time when residents are not engaged in programming is as important in positive outcomes as the activities they do during the day.
“My founding thought in the Eventide program was talking about sleep as the foundational medication for everything else that happens in that residence — day and night,” she said.
Eventide, which is currently being piloted in Frontier’s Auberge memory care communities in Chicago and Milwaukee, is geared toward residents who have harder times engaging with staff in activity programming during the day. It involves subtle changes to a resident’s environment made two to three hours before bedtime, such as blue light reduction and the introduction of aromatherapy and calming sounds, that become part of their regular routine, leading to deeper sleep cycles and better engagement during the day. Essentially, Eventide looks at sleep as a form of medicine.
Frontier is working with two groups in the Auberge communities piloting the program: residents whose engagement during normal programming lags behind the overall census, and residents with high existing positive outcomes.
Working with a team of physicians, Durkan identified five target metrics for success: improved activity engagement; changes in appetite; changes in average length of sleep in residents; a more fluid sleep cycle; fall reduction; and a change in the need for nighttime meds for sleep. The physicians will gather the results of the pilot and draft a white paper of the study later this year.
It is too early to determine if Eventide is effective, but Durkan is confident that enough data will be collected over the next 90 to 120 days to prove out her thesis. Additionally, the program will expand to Auberge communities in Arizona in the coming weeks.
“We’re looking [to improve outcomes] for residents where sleeping is really a challenge,” she said.
New design approaches
Covid-19 highlighted safety concerns for memory care residents. Specifically, providers are now looking at ways to break down the scale of their built environments, Jennifer Sodo, senior associate with architecture and design firm Perkins Eastman, told SHN.
She and Senior Associate Max Winters launched a 12-episode podcast series, “Shaping Dementia Environments,” that explores a range of innovations to upgrade the existing memory care design model.
Data suggest that communities in small house settings have fared better than institutional models during the pandemic. These environments have separate common areas and services. It is easier to isolate a specific group of people as opposed to a larger, commingling group. And while providers were exploring small home models pre-pandemic, that has gathered momentum over Covid-19’s duration.
Providers with small home memory care settings, meanwhile, are looking to scale down further and reduce the size of resident cohorts. Where there might have been 12 to 15 residents in these settings pre-pandemic, now providers are looking at groups settings of no more than eight people.
“Consider that as a large family. It’s easier to manage the routines and schedules of seven or eight people,” Sodo said.
The importance of outdoor access and spaces that connect to the outdoors is another area of importance, particularly in larger institutional environments, Winters told SHN.
Some of Perkins Eastmans’ clients were reluctant to embrace the importance of outdoor access, particularly in areas where weather conditions were not conducive to year-round use. But the pandemic has made these clients more receptive to the concept, and the firm is seeing a greater prevalence toward outdoor programming in design requests.
In smaller communities, Perkins Eastman is rethinking how memory care residents can receive visitors. Specifically, the firm is looking at dedicated space near the front doors of buildings, indoor or outdoor, which can act as a visitation room or a quarantine area, in the case of future viral outbreaks. These rooms can facilitate safe visitations without guests walking through different spaces in a building and increasing the risk of exposure.
Settings where memory care exists with assisted living and independent living are exploring dementia-friendly zones with amenities that allow memory care residents to commingle with neighbors in lower acuity settings.
“It’s sort of a middle ground where everyone can be,” Sodo said.
Perkins Eastman is persuading its clients to explore expanding the boundaries of common areas, to serve as connections between living units and the outside, similar to independent living residents being able to frequent shopping, restaurants and cultural institutions off site.
“It gives you connection when you want it, and isolation when you need it,” she said.
The firm believes the future of memory care design is essentially a back to basics approach, in which the built environment is nearly identical to residential home design. Homes have common spaces such as kitchens and living rooms, while dens, bedrooms and offices provide a measure of privacy. The same holds true for memory care environments, Winters told SHN.
But there is another layer where frontline caregivers use these environs for flexibility of care. If someone is having a bad day in a louder common room such as a living room, and may not be too excited about being moved to a dedicated quiet room, smaller scale designs allow for flexibility.
“It’s about using them creatively in the moment to respond to everybody’s needs, and not stigmatize or segregate somebody who’s exhibiting a particular behavior at a particular time,” Winters said.
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