Oasis of Calm

An older man in corduroys shuffles slowly down the bright hallway, turns around, and shuffles back the same way he came. And not for the first time. He feels the urge to leave, but the life he wants to return to is in the distant past. Like all the patients in the David Ward of the Evangelisches Krankenhaus Alsterdorf (EKA), a hospital in Hamburg, he suffers from severe dementia.

Nurse Svenja Ostojic gently takes hold of the man’s elbow and guides him to a seating area designed to look like a waiting room. “We could have designed this to look like a bus stop, too,” says the head nurse, “but that would’ve meant deceiving the patients.” After all, the bus would never come. Treating dementia patients with dignity requires empathy and, in many cases, creativity. “Please take a seat, Mr. Schulz,” says Nurse Svenja. “We’ll come and get you in a bit.” Mr. Schulz sits down next to the “Waiting Room” sign and watches the goings-on in the ward for a long while. “The patients are in their own world,” says the nurse. “We don’t want to put on a performance for them, but we also don’t want to keep confronting them with a reality that, for the most part, they don’t really see anymore.”

The David Ward is an internal ward especially for dementia patients who have been hospitalized as the result of another acute illness. It was established in 2011 and was the first specialized ward for internal medicine in Germany that was specifically tailored toward dementia patients. Dementia is prevalent among older patients in German acute-care hospitals. Nearly one in five patients over 65 is affected, as determined by a 2016 study, conducted by the Mannheim University of Applied Sciences and the Technical University of Munich and funded by the Robert Bosch Stiftung. “One thing dementia patients need is a special setting that would be very difficult to create on a general ward,” says Christian Kügler, who is responsible for the David Ward as the head physician for geriatrics and internal medicine. These patients might display defensive or aggressive behavior, or they might have the tendency to try to wander off, he explains. “That would be a little overwhelming for the staff of a general ward,” he says. Dementia patients on general wards are more frequently given medication to sedate them, or they are physically restrained, he says, which can trigger a delirium episode – an acute decline in brain function. “We have other options in the David Ward,” Kügler explains.

It’s six o’clock in the morning. Nurse Svenja arrives to take over ward duty from the night shift, alongside two of her colleagues and a trainee nurse. While the others sit around a table drinking coffee, the night nurse reports on the patients, explains which beds she had to put clean sheets on multiple times, and tells the morning shift which patients she had to pacify when they woke up screaming. Suddenly, they hear a voice from next door. “Hello?” One of the patients is already awake. She stands at the open door of the nurses’ office in her bathrobe; they smile and greet her back.

With one exception, the patients in the David Ward are over eighty years old. To make the patients more comfortable, many areas of the ward are set up to remind them of their younger days. The posters on the corridor walls feature the smiling faces of German and international celebrities of the past: Heidi Kabel, Freddy Quinn, Hans Albers, Humphrey Bogart, and The Beatles. The doors to the rooms are painted in different colors and labeled with large numbers so that the patients can find their way around more easily. The staff have a trick to prevent patients from leaving the ward: there is only one exit, which is located directly behind the nurses’ office – and it is disguised as an aquarium. There is a real aquarium built into the wall of the corridor in another spot; the “living room” is visible through the glass. This common room could be mistaken for a little museum of German interior design. There’s a shortwave radio from the 1950s, the two lamps are replicas of the classic Poulsen PH5 from 1958, and the striped wallpaper with roses is reminiscent of the 1970s.

At 7 a.m. Ms. Dierkes and Ms. Brinkmann are sitting in the dining room for breakfast. There are no fixed mealtimes for anyone – if patients want to sleep in and eat later, they can. Today’s date is hanging in extra-large format on the wall between the windows, beyond which are a blossoming tree, a few apartment buildings, and the radiant blue sky. Ms. Dierkes refused to eat when she was first admitted, but a trainee nurse is now patiently feeding her porridge spoonful by spoonful. Ms. Dierkes doesn’t speak, but after nearly every spoonful, she purses her lips and raises her shoulders. “You’re making a face like it’s sour,” says the trainee, “but it couldn’t be any sweeter!” She gently strokes the cheek of the old woman with short white hair and explains to her that some medication she needs is mixed into the porridge. The trainee and her charge are on a first-name basis; nurses only use the patients’ first names if the patients or their families request it. Ms. Dierkes doesn’t respond. Does she understand? It takes twenty minutes for her to finish her breakfast.

One-on-one care – with a great deal of tact

Time is a decisive factor in ensuring that dementia patients are treated with care and respect. Even in the advanced stages of dementia, patients still have their own will and the ability to understand and cooperate. “In order to learn what the patients want,” Dr. Kügler explains, “we need to get to know them. We need to take the time to observe their behavior. It requires a great deal of tact and good instincts.” Andreas Kruse concurs; he is the Director of the Institute for Gerontology at the University of Heidelberg and has been Chairman of the German Bundestag’s Aging Report Commission since 2003. He has done extensive research on this subject. “Any attempt to ignore their will, to disregard their autonomy, can cause a dementia patient to become unsettled, agitated, and yes, can even lead them to protest and reject the care being offered,” he says. “It’s vital for us to learn to read a dementia patient’s expressions and gestures; if we can do that, we can reliably determine when the patient is responding to a given situation positively, negatively, or neutrally.” This gives the staff a sort of compass for deciding which situations the patient can handle, and which situations they can’t, he says.

Nurse Svenja has been called to room seven; it’s the first time today that anything resembling a sense of urgency is palpable on the ward. Mr. Krüger is lying on the nearest bed. He was recently transferred from intensive care; he’s very weak and is hooked up to a feeding tube. He has just ripped the IV line out of his hand, removed his nasogastric feeding tube, and tried to stand up. Two nurses and a doctor are standing at his bedside, deliberating on what to do. “Maybe we do need to restrain him?” The doctor says quietly to Nurse Svenja. “No, I really want to avoid that at all costs,” she responds – and then turns to the patient and takes his hand: “Mr Krüger, we’re going to reattach your infusion tube now. Please don’t stand up!” Mr. Krüger stares at her in silence. “Promise you won’t stand up?” “Yes, yes,” he responds. “Really promise?” The patient gives her a slight nod. “Great.” The three medical staff members leave the room again. “We’re going to have to reattach that IV line more than once today,” is Nurse Svenja’s guess. Later on, they also replace his nasogastric feeding tube after consulting with his relatives.

A visitor arrives an hour before lunchtime. Music therapist Gertrud Ganser introduces herself in the dining room and starts the music – “This is a foxtrot!” Mr. Winter, an 80-year-old man wearing an elegant watch and nice shoes, offers her his hand; the two dance like a seasoned pair. “It’s wonderful to have a partner who can really dance,” says Ganser, visibly pleased. Then she puts on a Latin American song for Ms. Fischer, who can sing along and even translate the lyrics. “When you sing, your heart rejoices, too,” she says, interpreting the Spanish words of the song. Ganser laughs. Ms. Dierkes is next; she is sitting hunched over at the table. She has hardly moved since being fed her morning porridge. “I have something for you,” Ganser says and presses a button on her little remote control: “Oh, Donna Clara,” a tango from the 1920s, blares from the speakers; it’s a version performed by Alfred Hause and his orchestra. Ms. Dierkes looks at her, opens her mouth, and runs a hand through her hair. Ganser sits down across from her, runs her hand through her own hair, and mirrors Ms. Dierkes’ movements. This method sometimes helps staff make contact with unresponsive patients. After about thirty seconds, the old woman stands up, moves toward the therapist on wobbly legs, and reaches for her wrists. They smile at each other, hold each other’s arms, and dance in place – an unexpected turn of events for the others in the room, who are watching with interest. Ms. Dierkes also stands up for the last song and sways back and forth. “Would you like to sit down again?” the therapist finally asks, taking the patient gently by the elbow and guiding her back down into her seat. “I’ll just push you in a bit closer – see you next time!”

In the corridor, Ganser tells Nurse Svenja about her unexpected dance partner (“Ms. Dierkes really warmed up to us today!”), while Mr. Winter – the good dancer – takes a seat next to Ms. Dierkes in the common room and talks to her. After a few moments, she takes his hand. Through the flower stickers on the plexiglass window, they catch a glimpse of Mr. Winter giving her a friendly stroke on the cheek – this woman who had previously seemed so withdrawn and isolated. “Sometimes, the music sparks something good in people, and that spark spreads,” therapist Ganser explains, pleased.

Internal wards like the David Ward in Alsterdorf are still rare in Germany. “And yet, these types of wards significantly lighten the workload for the general wards,” Christian Kügler says. But the head physician warns that having a special ward doesn’t mean the rest of the hospital never has to deal with dementia patients. The staff on the general wards still need to be able to diagnose advancing dementia and to treat less severe versions of the condition with sensitivity. “That’s why all the staff at our hospital receives special training, not just the people working on the David Ward.” The Robert Bosch Stiftung supports the efforts of the EKA and 16 other hospital locations in Germany to make all of their facilities suitable for treating dementia patients with dignity.

Gerontologist Kruse firmly believes in the David Ward model. “In order to implement a model like this across the board,” says the Heidelberg-based researcher, “we need to raise significant awareness among hospital managers of the responsibility that we all have, as part of our day-to-day work in the hospital, to guarantee a decent quality of life for our dementia patients.” Kruse feels that decision-makers at health insurance companies are also called upon to act; after all, this model requires significant investment of resources. A study conducted by the University Clinic Hamburg-Eppendorf (UKE) investigated the effectiveness of the David Ward and determined that funding provided by the health insurance companies did not cover the additional personnel costs the ward requires.

However, even if this type of ward is not cost-effective for an individual hospital, it could very well pay off for the health care system as a whole. “On the David Ward, we can prevent patients from falling, and we administer fewer antipsychotics,” says head physician Kügler – and as a result, he suspects, the patients feel better for longer, spend less time in the hospital overall, and do not need to go into a nursing home until later. The UKE study supports this hypothesis; it determined that the economy benefits from the prevention of subsequent costs.

It’s one o’clock in the afternoon. An hour before the end of her shift, Nurse Svenja also experiences some of the benefits of the music therapy session from earlier in the day. While the other patients have already been served lunch, Ms. Dierkes is still sitting at an empty table. When Nurse Svenja passes by, Ms. Dierkes calls out. The head nurse kneels down next to her. “Hello, dear, would you like something to eat?” By way of an answer, Ms. Dierkes kisses her on the cheek. “Sure, there are days when I go home with a headache,” the nurse says a little later, “but today was a really great shift. It was a fantastic day.”