It takes a village – new approaches to dementia

“Doctor, I’m worried about my memory” or “Doctor, can I have a word with you about my mother” are phrases that are all too common to us as GPs. These are phrases that unfortunately are likely to become all the more common, with Ireland predicted to have the largest growth in terms of an older population of all European countries in the near future.

Currently it is estimated that 50,000 people suffer with dementia in Ireland – with this figure expected to rise to over 150,000 over the next 30 years. Throughout my GP training and again now as a practitioner, looking at how Ireland deals with dementia, how we care for these patients and exploring other strategies in relation to dementia care has become more and more relevant. 

Consequently, in my final year of GP training, we decided to look at some of the European models of care in relation to dementia. We looked particularly at the Dutch model, and how they have implemented innovative strategies, such as the ‘Dementia Village’ in relation to their model of care. We decided to travel there as a group in 2016 to examine, question and personally experience how this idea functioned in relation to dementia care.

Familiar surroundings

The idea of creating a ‘dementia village’ occurred over 25 years ago, when two nurses working in the traditional nursing home system came to the conclusion that allowing people to live in largely familiar surroundings, instead of places unfamiliar to them, could only be better for their cognition. It wasn’t until 2009 that their vision became a reality.

A small village called Weesp, outside Amsterdam, became the home to Hogewey – colloquially called the Dementia Village. Hogewey is a residential complex, consisting of 23 houses for 152 people suffering with severe dementia. These houses are divided by seven different lifestyles – reflecting the makeup of Dutch society and a typical Dutch city – with examples such as a Christian household, rural household, Dutch Indonesian household or indeed an ‘Upper Class’ household.

Each household enjoys different meals, schedules and participation in clubs and activities that are traditional to their former life. For example, the Christian residents have allotted time for religious activities, while those in the cultural complex participate more in art, model-making, etc.

The houses themselves are constructed and designed in a manner familiar to these residents, with design features similar to what they would have had in their own homes prior to entering the complex.

Outside, the surrounds contain a supermarket, public house, theatre and small park – all of which are accessible to the residents. There are approximately 240 staff members employed in the unit – from those working in the supermarket and the restaurant, to carers who work in each residential unit. Each member of staff is specifically trained in how to deal with these patients, how to encourage involvement in activity and how to stimulate the patients into interacting with each other. 

When we visited here, we were fascinated to see how this model worked in comparison to our traditional view of nursing home care for dementia patients. Here, there are no wards, no traditional nursing offices or long corridors. Instead, we entered a unit that simply represented a smaller version of the town we had left outside. 

Accompanied by one of the founders, Yvonne van Amerongen, we wandered around the small streets, did a little grocery shopping in their supermarket and sat in on a music class with the cultural household that was happening that afternoon.

Replicating normal life for patients

What struck us all as trainees, was how interactive all these patients were – how happy they all seemed to be and how few of them seemed to be confined to a bed, as we had all frequently experienced at home. 

Sitting in the village restaurant, we explored some of these issues with Ms Van Amerongen. She explained that the facility largely strives to replicate normal life for these patients. Rather than use sedation at night, there are night-time sensors placed around the facility so that staff are aware if any patient gets out of bed. Benzodiazepine prescription is strongly discouraged, thus increasing patient activity and interaction throughout the day. 

There are social workers on call, so if a resident is anxious, agitated or angry they can be cared for in a calm and positive manner. Yet, we questioned why, if the system is so good, is there only one of these villages established in the Dutch system currently?

Home care for as long as possible 

Interestingly, especially now as the HSE Fair Deal has become such a hot topic in Ireland, she explained that the Dutch model largely tries to encourage patients to be cared for in their own home for as long as possible and the cost of this is supplemented. The idea behind facilities such as Hogeway is that they are only for those with severe dementia who can no longer be cared for in their own environment. The other issue preventing the creation of more of these complexes, as in most healthcare projects, is in terms of finance. 

The village itself cost in the region of 23 million euro to build – with the government supplying 22 million and sponsorship needed for the remainder. The café, theatre etc are now all open to the public to generate income for the village. The Dutch government, through the public health insurance system, supplements each patient, with families and patients themselves also contributing towards supplementary facilities and outings. Through creative innovation such as this – the village has thrived.

The visit opened our eyes as trainees to how we view dementia care and how we should be approaching this complex issue in our own country. It also emphasised to us as young practitioners the need to focus on dementia as an issue that will increasingly affect us in practice in the future. 

As trainees at the time, it also revealed the importance of actual implementation of the Irish National Dementia Strategy, and the need for both trainees and practitioners to become involved in education strategies such as PREPARED, which was discussed within the January and Feburary issues of Forum. Educating ourselves and actually implementing the ideas within these strategies is essential, not only for us as GPs but also for the benefit of our patients.

Restrictions of reality

Coming away from the dementia village, we all recognised that in an ideal world, forms of care such as this would exist in all countries for those who required and were suitable for such a system. Yet equally, we realised that realistically, the funding for a facility such as this simply is not available in Ireland’s healthcare system at present. 

What we did bring back to our practices however, was the realisation that elements of the ideas behind the village could be incorporated into existing practice here. Ideas such as increased encouragement of activities, recognising the importance of cultural, spiritual and educational events, and the use of more considered prescribing when attending these patients all became clearer. 

Recognising that those with dementia can still live an enjoyable, active, and indeed happy life is something that we all need to take into account as medical practitioners. 

Therefore, next time we speak to that family member who wants to talk about their mother’s memory, maybe we can consider some of these options and encourage the use of some of these strategies in terms of our overall approach to dementia in Ireland for the future.