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October 21, 2020 drfreedman_250.jpgFor many years now, severe responsive behaviours, aggression, confusion, hallucination and depression, found in individuals with dementia, have been a growing public health concern in countries like Canada with an aging population. Today, in the current climate of the COVID-19 pandemic, patients suffer even more because responsive behaviours are spiralling due to disrupted routines and limited access to therapy and social interaction.  

Dr. Morris Freedman, Behavioural Neurologist and Mindy Halper, Nurse Clinician at Baycrest are tackling this crisis through the Virtual Behavioural Medicine Program, a pilot project involving the Baycrest Sam & Ida Ross Memory Clinic and Behavioural Support for Seniors Program TC-LHIN (BSSP TC-LHIN). This novel approach led by Dr. Freedman has reduced the need for those clearly requiring admission to specialized behavioural units by about 80 per cent. The program has demonstrated remarkable success because its virtual format has enabled the team to respond quickly to support clients, foster collaboration with system partners, and provide caregivers with the support they need.

Immediate support
The Memory Care Program at Michael Garron Hospital is seeing a growing number of dementia patients with responsive behaviours. Dr. Pieter Jugovic, Director of ALC, Chronic Ventilation, and Rehabilitation Programs at Michael Garron Hospital, shares the impact the Baycrest program has had on his work: “We are seeing an increasing number of dementia patients with challenging behaviours, which no one in-house is equipped to deal with. It is so helpful to have access to someone like Dr. Freedman who can walk you through those behaviours and help us respond appropriately.”

Since the program's launch this year, the Baycrest Behavioural Neurology Unit’s one-year waitlist has been eliminated. Physicians and caregivers can see a major improvement in patients' behaviours as care is available as soon as behaviours are triggered.

Dr. Jugovic says, “Normally getting support would take months, and now, through the Virtual Behavioural Medicine program, we have support as soon as we need it. My team is fantastic, but they don’t have the specialized knowledge needed to address the more challenging patients. A behavioural neurologist such as Dr. Freedman has knowledge and expertise so far above that of an average clinician. I am so grateful that we have access to his skill and expertise; it is a unique gift for which I call him ‘the dementia whisperer.’ I am not sure what we would do now without this expertise.”

Collaboration with system partners
The program has fostered collaboration with system partners, including long term care (LTC) primary care providers and medical directors, BSSP TC-LHIN supports in acute care, LTC and community, and geriatric mental health outreach teams. It is a richer experience for everyone because of the multidisciplinary expertise needed.

Beverly Van Buuren, Clinical Services Manager, Seniors’ Health at William Osler Health System, says, “Our team has weekly calls with Dr. Freedman and Mindy Halper to discuss our patient. Anytime we have had questions, the Baycrest team has really listened to what our concerns were with regards to our patients’ needs. Dr. Freedman and his team listened intently and took what was said into serious consideration.  The team asked appropriate questions to guide the treatment and provided rationale not only to our team but to the family as well. This is invaluable to us as our goal is to provide our patient population with the best possible outcomes.”

This type of collaboration is new and only possible because there are no geographical boundaries. All staff members who are providing care at the LTC homes and acute care hospitals can actively participate in the specialist assessment process. They are providing feedback, asking questions, and noting progress on strategies that were recommended – they are active participants in that process.

Caregiver support
When we were in the thick of the first-wave, the toll and stress experienced by caregivers and dementia patients was immense. Lisa Raitt shares its ramifications on her husband, Bruce, a Baycrest patient diagnosed with early-onset dementia. She says, “This summer, Bruce started exhibiting very difficult behaviours. If we didn’t have access to the Virtual Behavioural Medicine program, Bruce would have had to be hospitalized for a number of weeks. He was a danger to my kids and me.”

The support Lisa received from Dr. Freedman and the Virtual Behavioural Medicine program has mitigated the responsive behaviours and has allowed Bruce to stay at home with his family. Lisa says, “Bruce is no longer experiencing the violent outbursts that he was in the summer and this is only possible because of the regular support I get from Dr. Freedman and Mindy Halper. I was told to report behaviours and incidents to them on a frequent basis, and we could actually deal with behaviours in real-time. Bruce would have an incident, and I could show it to them through the laptop.”

The support provided by the program is, in fact, showing better results than the in-person format because the clinical team can work with patients and their caregivers in their home environment, where they are comfortable. When individuals with dementia are uprooted from an environment they are comfortable in, it is stressful for their caregivers and them and could trigger more responsive behaviours.

Lisa explains that well before the severe responsive behaviours were triggered, it was exceedingly challenging for her to get Bruce assessed properly and take him for his medical appointments. She says, “For the first time in four years, we have been able to do the tests and assessments that we could not do before. Dr. Freedman spent a full hour and 20 minutes with Bruce to do the testing that was needed, allowing him to make a diagnostic decision. It was a friendlier environment at home for Bruce. We didn’t have to travel all the way to the hospital, and it was less threatening to Bruce because he could walk away if he wanted to.”

While the cognitive decline that was hastened by the pandemic cannot be reversed, Lisa is relieved that the behaviours are now manageable. She says, "Nothing can reverse the cognitive erosion, but the program mitigated the behaviours, which were the problem. Without this treatment, it would have been far worse – inconceivable. We would not have been able to continue the way we were living before."

A new and better way of delivering care
The virtual care model for assessing and managing responsive behaviours in dementia represents a new and better way of delivering medical care for individuals with responsive behaviours. Through this innovative approach, the program aims to scale the impact and build capacity across the country to serve Canadians' needs across all provinces and territories virtually and without limitation by geographical barriers, ability to travel, or local health care resources. Such collaboration will support equitable access, reduce unnecessary financial costs, prevent caregiver burnout, and better manage severe responsive behaviours.

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