The Flexibility Approach To Dementia Care: Is It Worth Exploring?

There are an estimated 4.5 million Americans suffering from Alzheimer’s Disease and dementia. It has also been forecasted that this number will triple to 16 million by the year 2050 (Alzheimer’s Association). As the country focuses more on health care expenditures due to the baby boom generation hitting the elder years; national direct and indirect costs related to Alzheimer’s and dementia was 100 billion in 2005 (National Institute of Aging, 2005).

Consequently, as health care trends become more complex to interpret, the current nursing shortage has began to make an impact on the delivery and quality in care. Particularly in nursing home institutions. Innovative approaches will be required to address these vital issues, as the baby boom generation begin to take advantage of their Medicare and Social Security dollars.

Dementia is a condition of the brain which causes a gradual loss of mental ability. In addition, other features commonly develop such as changes in personality, a decline in social function, and a decline in the ability to look after oneself. Dementia is not a single disease as there are various different causes (National Institute of Aging; Alzheimer’s Association).
“Dementia usually affects older people and becomes more common with increasing age. Sometime after the age of 65 about 1 in 20 people develop dementia. About 1 in 5 people over the age of 80 have dementia. Rarely, younger people develop dementia. Dementia is not a normal part of ageing. It is also different to the mild forgetfulness that is common in many older people (Alzheimer’s Association, 2003, 2004, 2005).”

Dementia can be caused by various diseases which affect the parts of the brain involved with thought processes. However, most cases are caused by Alzheimer’s diseases or vascular dementia. All of the types of dementia cause similar symptoms, but some features may point to a particular cause. So, quite often it is not possible to say which disease is causing the dementia in each individual case (National Institute of Aging).

Alzheimer’s disease
This causes about 6 in 10 cases of dementia. It is named after the doctor who first described it. In Alzheimer’s disease the brain shrinks (atrophies) and the number of nerve fibres in the brain gradually reduce. The amount of some brain chemicals (neurotransmitters) is also reduced, in particular one called acetylcholine. These chemicals help to send messages between brain cells. Tiny deposits or ‘plaques’ also form throughout the brain. It is not known why these changes in the brain occur, or exactly how they cause dementia (National Institute of Aging).

There is no way of predicting who will develop Alzheimer’s disease. It is not hereditary and anyone may develop it.
Vascular (‘blood vessel’) dementia
This causes about 2 in 10 cases of dementia. This is due to problems with the small blood vessels in the brain. The most common type is called ‘multi-infarct’ dementia. In effect, this is like having many tiny strokes throughout the ‘thinking’ part of the brain. A stroke is when a blood vessel ‘blocks’ and stops the blood getting past. So, the section of brain supplied by that blood vessel is damaged or dies. As each ‘infarct’ occurs, some more brain tissue is damaged. So the mental ability gradually declines.
The risk of developing this type of dementia is increased by the same things that increase the risk of stroke. For example: high blood pressure, smoking, high cholesterol level, lack of exercise, etc.

Flexibility Approach

As the baby boom generation takes it place as the new older cohort, new paradigms and approaches have been entertained in nursing home care to accommodate this demanding cohort. Among the many interesting paradigms, “flexibility” in dementia care (Cohen-Mansfield & Bester, 2006) has received significant attention. This paradigm combines the emotional intelligence of clinical care and the business savvy of a decentralized institution.

Addards, a 30 bed skilled nursing facility in Tasmania, Austrailia, that specializes in dementia care offer its’ residents and employees “flexibility” in care, work and environment. The director of nursing summarized his philosophy about the role of staff members in the following way: “if, when I come into the unit in the morning I see all the beds are made, and the residents are dressed, I am concerned. But, if I see that not everything has been done, and that staff members are eating breakfast and joking with the residents, I know everything is fine.”

The Model of Flexible Management utilized in this care model focuses on the residents and faculty’s sense of control and comfort levels. In return, employees, particulary Extended Care Assistants (ECA) are able provide “individualized” care in an “flexible” environment as indicated by the Director of Nursing. In this environment, it is hoped that the catalysts for innovation: sense of control, sense of comfort and individualized care would positively impact the well being and better affect the lives of the 36 residents at Addards. As a result, improved behavior and family satisfaction are the benchmarks or milestones linked to quantifiable success.

Even though the study made some useful comparisons to nursing full time equivalents (FTE) in the US. US minimum average standards of licensed staff .41 and 2.32 total staff including (Nursing aides) respectively. This does allow for future dialogue which challenges the usual scheme of things in terms of how to approach nursing shortage and employee satisfaction in skilled nursing facilities. Centers for Medicare as of late, have been quite diligent in their efforts to manage this unique and complicated process. With proposed requirements of 1.3 (licensed) and 4.1 (total staff) in the near future, it appears this flexibility approach introduced (Cohen-Mansfield & Bester, 2006) may gain some traction in the US. Is it time to approach these complex issues with rigor and innovation as it relates to this new paradigm of care for dementia patients? In my opinion, the answer is yes.


Cohen-Mansfield & Bester. (2006). Flexibility as a Management Principle in Dementia Care: The Adards Example. The Gerontologist, 46, 4 540-544.

Patient UK. [Online]. What is Dementia. Retrieved October 10, 2006 from

National Institute on Aging. [Online]. General Information on Dementia. Retrieved October 11, 2006 from

Alzheimer’s Association. [2006]. Statistics about Alzheimer’s Disease. Retrieved on October 20, 2006 from

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2 thoughts on “The Flexibility Approach To Dementia Care: Is It Worth Exploring?”

  1. Dear Walls,

    Thank you for responding. In response to your question. I agonized over this particular statement, but I stand by it. During the past five to ten years, the premise of your question [relates] to chromosome 14 & 19, which have been linked to the late onset of AD (stage III). But the overall body of research [in this arena] is still ongoing and inconclusive.

    Moreover, the premise of this submission was to introduce an innovative approach to a complex care model in skilled nursing facilities in the US(as we experience nursing shortages). The reason why I provided background for AD and dementia, was to demonstrate how complex AD and demential care is and how this complexity relates to institutional care.


    Dr. Eugene Jacquescoley
    AAAS Member
    APHA Member
    GSA Member
    ACHE Member

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