THE STANDING SENATE COMMITTEE ON SOCIAL
AFFAIRS, SCIENCE AND TECHNOLOGY
OTTAWA, Thursday, May 12, 2016
The Standing Senate Committee on Social Affairs,
Science and Technology met this day at 10:30 a.m., to continue its study on the
issue of dementia in our society.
Senator Kelvin Kenneth Ogilvie(Chair)
in the chair.
Welcome to this meeting of the Standing Senate Committee on Social Affairs,
Science and Technology.
I'm Kelvin Ogilvie from Nova Scotia. I would like to start by
asking my colleagues to introduce themselves.
Senator Seidman: Judith Seidman from Montreal, Quebec.
Senator Stewart Olsen: Carolyn Stewart Olsen from New
Senator Raine: Nancy Greene Raine from B.C.
Senator Merchant: Pana Merchant from Saskatchewan.
Senator Eggleton: Art Eggleton from Toronto, deputy chair
of the committee.
The Chair: The committee is continuing its study on the
issue of dementia in our society. We have two witnesses today.
I welcome back and invite Dr. Frank Molnar, Vice-President,
Canadian Geriatrics Society, to present. He is appearing this time as an
individual. Dr. Molnar, please.
Dr. Frank Molnar, Vice-President, Canadian Geriatrics Society,
as an individual: As a practising specialist in geriatric medicine, I feel I
can be of greatest help to you by sharing the harsh realities of dementia care.
I have been reviewing the transcripts of previous witnesses and find they have
done an excellent job in outlining the investments that have been made to date.
Despite all the investments, acute care hospitals are being overwhelmed by the
care of persons with dementia. We do not have the resources to meet their needs.
We are losing ground and need immediate help.
Hospitals were never designed to care for persons with dementia.
When admitted to hospitals, persons with dementia suffer avoidable and prolonged
deliriums. They often do not make a full recovery. They suffer avoidable
deconditioning, and they lose the ability to walk. Hospital-acquired delirium
and hospital-acquired deconditioning lead to high levels of hospital-acquired
disability. This in turn leads to long lengths of stay at $1,000 a day, high ALC
— alternative level of care — rates, and premature long-term care placement. We
are wasting precious health care resources without providing the care needed in
Given these realities, I wonder whether Accreditation Canada
should be asked to develop a required operating procedure which ensures that
every acute care hospital has a dementia, delirium and behavioural management
service, ideally supported by both geriatric medicine and geriatric psychiatry.
When properly implemented, these services would pay for themselves in cost
savings, not to mention the suffering they would prevent.
Strategies to help hospitals deal with the escalating numbers of
persons with dementia must start upstream in the community to prevent admissions
in the first place. Due to hospital financial challenges, many specialist
clinics that care for community-dwelling persons with dementia are suffering the
death of a thousand cuts. Downsizing and closing these clinics will predictably
increase hospital admissions of persons with dementia. We are moving in the
wrong direction. That is the bad news.
The good news is that this maybe partially offset by the primary
care-based dementia clinics that are developing all across Canada. The model
that I know best is the Linda Lee primary care collaborative memory clinics that
are rapidly expanding in Ontario. We may have as many as 100 in a few years.
These primary care teams are linked to specialists in geriatric medicine and
geriatric psychiatry, with the goal of creating a collaborative care model and
preventing a silo of care. We recognize that one size does not fit all and we
probably need a suite or a series of different primary care, collaborative care,
shared care models.
The other promising model in Ontario is the Health Links model,
which is focused on intense system navigation and care coordination or case
management of the most complex patients. Ideally Health Links could be expanded
to include the care of medically complex persons with dementia whose needs have
exceeded the resources of primary care memory clinics or specialist clinics, in
effect an escalation of investment to prevent avoidable hospital admissions.
These acute care and community care mitigation strategies require
that we rapidly escalate or increase the number of specialists in geriatric
medicine, care of the elderly and geriatric psychiatry. This begins with
education and exposure. Despite the fact that almost 50 per cent of health care
budgets and 60 per cent of admissions to hospital are accounted for by seniors
and that dementia is the number one driver of ALC, the study of seniors care and
dementia care is not required in all medical schools and in all internal
medicine programs. There is a clear disconnect between societal need and what
universities feel they must provide. We need national accreditation bodies to
insure that seniors care and dementia are properly integrated into the
An all-party caucus on seniors care has been struck. Given the
high incidence and prevalence of dementia in the senior population, this should
include the study and care of people with dementia.
The federal government has signalled its intent to sign a new
health accord. The need for action on seniors care, including dementia care,
should be part of that accord.
Finally, a national dementia strategy incorporating some of the
elements I mentioned could significantly assist provinces in their efforts to
decrease wait times. If properly designed and implemented, this could save money
while freeing up acute care and nursing home beds. Any organization formed to
take on this critical role must have federal and provincial decision makers with
the authority to shift funding to re-engineer or repurpose existing resources.
Without that level of control, a national dementia organization will not have
the resources necessary to make the widespread changes required.
With federal leadership, provinces joining such an overarching
dementia organization could benefit from a number of items, including shared
public education; national health literacy resources for persons with dementia
and their families that primary care practitioners and specialists could use;
the development of a home-care-plus model that integrates specialists in
dementia care right into the home care model; a national repository of leading
best practices with supporting cost-effectiveness research; the development of
robust new acute care dementia strategies; and enhanced accreditation standards
for hospitals, home care and universities to insure they provide appropriate and
meaningful dementia education, training and services.
In conclusion, the Canadian Geriatrics Society, as the
organization representing specialists trained in the care of medically complex
and often medically unstable persons with dementia, would be honoured to
contribute to such a national organization.
The Chair: I am now pleased to turn to Ken McGeorge,
Acting Executive Director of the Alzheimer Society of New Brunswick.
Ken McGeorge, Acting Executive Director, Alzheimer Society of
New Brunswick: It is an honour to be here. The reason for the acting title
is that I have retired three times. This is my third post-retirement gig. I am
doing a maternity leave coverage as the CEO of the New Brunswick Alzheimer
Society and having a blast doing it, actually. As my kids would say, it is one
of the most fun and most satisfying jobs I have had.
It is an honour to appear before you and share my passion and the
passion of every one of the 12 volunteers who constitute our board and form the
Alzheimer Society of New Brunswick.
I am a career health executive with experience administering
significant teaching hospitals in Kingston, Ontario; Halifax, Nova Scotia;
Fredericton, New Brunswick; and a few non-teaching hospitals as far away Red
Lake, Ontario. My career also included experience working in the civil service,
which afforded me a public policy perspective that has been valuable. I started
my career at 19 years of age, delivering direct patient care. I draw on that
experience every day of my professional life.
Our national leader, Mimi Lowi-Young, CEO of the Alzheimer
Society of Canada, spoke to you on March 23 about the need for a national
dementia strategy. Regarding a national dementia strategy, I can say that the
Alzheimer Society of New Brunswick wholeheartedly, without any reservation,
supports that initiative.
Hundreds of thousands of Canadians living with dementia are
counting on the Government of Canada to lead the way.
We know that the risk of dementia increases rapidly with age. In
the Atlantic provinces, we boast that we are older than the rest of you. Nova
Scotia and New Brunswick are tied now. As a matter of fact, I think someone said
recently we beat out Nova Scotia already. That is kind of interesting.
Cancer was the disease of the last century. I have been around
long enough to see how the care, treatment and diagnostics process of all that
has evolved over 50 years. Now we need to do the same with dementia. Our failure
to do that will lead to unprecedented stress in the health system. It's stressed
enough now. If we don't act now, then there will be significantly more stress.
For our association in New Brunswick, our vision statement ends
with “defeating the dark shadow of dementia.” Every disease has a dark shadow;
dementia has that dark shadow, and it goes like this: First, we have yet to beat
the stigma that goes with dementia. We should have. We're grown-up people, but
that stigma is still there, alive and well, unfortunately. It serves as a source
of imprisonment for families, frankly, certainly for caregivers and for the
person with dementia.
Family caregiver distress is legendary now. Everywhere you go
when you talk about dementia you hear “caregiver burnout.” It's just there as
part of the language.
Alzheimer's disease and dementia need to be accepted as major
chronic diseases. They are not yet but need to be.
The next element of the dark shadow is the whole issue of
navigating pathways of diagnosis, treatment and support, which is quite
frustrating for most persons dealing with that disease. It is less so in some
provinces, more so in some others. In New Brunswick, we're working on it.
There are significant inappropriate treatment practices, with
hospitals all too often being the default position, and very inappropriately so
for many reasons.
Finally, and this one has really hit me big time as I interact
with clients who come into our various offices in New Brunswick, there is the
loss of hope that families experience once the diagnosis is made. They have
dreamed of a wonderful, healthy retirement going to Florida, or wherever they
are going to go, and all of a sudden the partner is stricken and all of that is
dashed and gone. And that needs to be recognized as a real factor. Everything
that we do as a society in New Brunswick targets those elements.
A coordinated national dementia strategy will provide a focus for
dealing with the dark shadow in a coherent and systemic way. That is what
happened with the national cancer strategy, and that's what needs to happen with
the national dementia strategy.
In New Brunswick, we have or are developing a full repertoire of
services for persons with Alzheimer's disease. Our repertoire is not yet fully
fleshed out, but thus far it includes some of the following items: First, we
have our five-part education series, which is first and foremost for people even
before diagnosis to give them some really good education on a whole host of
issues that they will face through the journey. Second, we are proud of some of
the support groups that provide wonderful support to caregivers, and caregivers
who are not part of those networks really do suffer for not participating.
We have memory cafés. I understand somebody expressed an interest
in that recently here. In any event, memory cafés are a wonderful tool that we
are introducing around New Brunswick with phenomenal results, and phenomenal
results as well with the iPod project, which is being used in a variety of
places as a wonderful alternative to overmedication; it is a fascinating thing.
Minds in Motion is a program we hope to kick off this fall in
conjunction with the kinesiology department at UNB. We do a lot of public
education, travelling all over the province and speaking to groups. We have a
library of phenomenal resources. We do family counselling support, and we have a
wonderful program of follow-up with families so that they don't get lost in the
Downstream, and flowing from a systemic strategy that we would
like to see flowing out of a national dementia strategy, would be five things: a
sharper and more coordinated research focus; improved standards of care and
improved consistent standards of care across the country; standardized training
for those who deliver dementia care; readily accessible best practice
information — that is really difficult to come by right now; and, finally,
widespread use of all available technologies. There are some wonderful
technologies out there that can help caregivers, but in our area, at least, the
majority of caregivers are not aware.
The proposed Canadian Alzheimer's disease and dementia
partnership is a model that can serve to advance the strategy. It's based on the
Canadian Partnership Against Cancer. The cancer partnership is a good working
model. The dementia strategy doesn't necessarily need to replicate it entirely,
but certainly some of the wonderful principles are there.
The scale, impact and cost of dementia mean that no single
province can tackle dementia on its own. Some will do better than others, but a
national approach is really needed.
A national dementia strategy would help to ensure that all
Canadians living with dementia will have the same level of access and quality of
care and services regardless of where they live. It would level the playing
field, not only between regions and provinces but between urban and rural
Finally, without a level of pan-Canadian leadership by the
federal government, I believe — and I said this earlier and am repeating it for
the sake of repetition and emphasis — we will invite some huge problems if we
don't deal proactively.
Thank you very much.
The Chair: Thank you to you both.
Senator Eggleton: Thank you very much to both of you for
Dr. Molnar, in two and a half pages you have given us the state
of the nation on dementia in precise terms. You finish off by referring to
federal leadership with the provinces joining to form an overarching
organization. How would you see we get the ball rolling on that? What
organization would take the lead?
Dr. Molnar: The first question is a bit easier than the
second question, which I'm sure you struggled with throughout the hearings.
In terms of getting the ball rolling, there are certainly
different approaches. One that seems to work regionally and provincially, and
you'll have to see if it works nationally, is a project-based approach to start
with some things that people can achieve, such as items 1 and 2, the shared
public education, which I think Public Health is actually doing fairly well with
the national health literacy resources or standards of care. Is there something
that all dementia health care providers can go to that's a standard across the
country so that they all know how to provide the same care in the same way and
they have the same handouts and can provide the same education for families and
persons with dementia?
The repository of leading best practices I think is really
critical, and that is one I wanted to talk about in greater detail. Leading best
practices are tricky. As we've mentioned before, Canada is the nation of a
million pilots. We don't move from pilot studies to outcome studies. As a
researcher, my definition of pilot study is one that doesn't have a sample size
that's adequate to generate the outcome. It just shows you can do the larger
study. So we often don't move on.
Some people do promote services that have just gone through a
pilot as a leading best, and I've been involved in those exercises where there
is really no cost-effectiveness information. We do need a national body that
really sets the standards for what is needed to make decisions, what type of
research is made, and which of these pilot studies we will invest in going
I think CIHR does that to a degree, but perhaps we need to be a
bit more focused in saying we need to know more about dementia health services.
We need to see which of these are translatable and how we can move more pilots
It's very interesting, in reading the transcripts, a tonne of
stuff is being done in research, but it's not reaching the ground. It's not
reaching people like me who are providing front-line care. So there are really
two worlds: There's the research world, and there's the clinical world, and the
two are not meeting very often.
That type of leadership and that type of push to get some of the
most promising pilots into larger-scale research or to even try them in the
field would be an excellent start. In my experience, starting with specific
projects is important. That being said, the point I made in the page before that
ultimately this organization needs to have the levers to make change is also
critical. If you don't have the financial levers to fund new services or to move
funding to reorganize or re-engineer services, we will not get very far.
People love to hear plans about the nature of seniors care, and
everyone supports them until they realize that the funding will shift from
somewhere else because health care is a zero-sum game; there is only so much
money in the pot. We need a combination of both — one, an organization that can
push the right projects forward; and, two, an organization to shift money and to
re-engineer services. I have no idea who has that kind of authority; maybe it
doesn't exist yet.
Senator Eggleton: You think it needs to be an organization
outside of government? That is, a partnership of all the different organizations
or stakeholders in the dementia care field?
Dr. Molnar: I think it needs to be an organization that
integrates government, where government is a central part of it, because we need
those people who hold the purse strings to make the hard decisions.
Senator Eggleton: And the role of the Public Health Agency
of Canada or Health Canada in all this?
Dr. Molnar: They have been doing a great job in terms of
public education, but that needs to be scaled up.
How do you prevent dementia? As previous witnesses have said,
it's very much the same things you do to prevent heart attacks and strokes. Some
of the obesity work that you have done in previous sessions feeds into that. How
do you prevent dementia? How do you align these diseases together? How do you
recognize dementia and get help?
Senator Eggleton: I had a meeting earlier this morning
about palliative care with a doctor from the West Coast. You don't mention
palliative care in your document here. How do you see that all fitting in? There
is some question that we need better coordination.
Dr. Molnar: There is certainly an overlap between dementia
care, geriatric care and palliative care. The palliative care we provide to
people with dementia is lacking in a scientific foundation and in coordination.
It’s what I actually do for a living. I am on consults right now in my hospital,
and I help the surgeons realize that these persons will not survive. They will
not live, and I help them understand that we have to move on to a palliative
care or end-of-care comfort stage of life.
I think there is a big overlap. The palliative care group needs
to have input from the dementia world so that we can overlap our efforts and
make palliative care appropriate for families who are caring for someone with
Senator Eggleton: You mention dementia plus. When you were
here last, you had a program called GEM Plus. Is that the same thing?
Dr. Molnar: No, it's perhaps a term I like to use too
often. With dementia-plus care, in my mind I differentiate two types of dementia
care that specialists provide. However, this doesn't account for the other types
of dementia. One is dementia diagnosis and drugs. We see that in a lot of
dementia clinics. That's the focus, namely, the diagnosis, the drugs, the start
of the journey. The other part of the journey is dementia-plus care. That is,
what do we do as the person with dementia develops the other chronic diseases?
We know that 90 per cent of people with dementia in the community have two or
more other chronic diseases. That's why they end up in hospitals, and that's why
dementias drive ALC.
How do we start to coordinate that? Geriatric medicine was
specifically designed for that. We are cross-trained. We are internal medicine
specialists cross-trained in psychiatry and neurology. It is coordinating the
diseases together. How do you care for a person with dementia when they have
heart failure and diabetes? I think the primary care memory clinics are a nice
venue for that because the primary care providers are generalists and they
understand the other diseases.
Senator Eggleton: I may come back to you later, but I
would like to get a question in with Mr. McGeorge before my time is up.
Memory cafés started in the Netherlands, we're told, in the late
1990s. You seem to have had more success picking them up than any other province
in this country. How long have you had them? I understand the general purpose of
them, but have you done some evaluation to determine how well those are working?
Mr. McGeorge: We have only been at that for about a year.
As of right now, we have eight in this small province. The goal is to get at
least 13 up and running by this summer.
Evaluation has been, thus far, unfortunately, anecdotal. Having
said that, we are working with UNB researchers to do a more broad-based research
evaluation of them, when we have enough experience. Thus far the anecdotal
evidence is just — I don't care about the research; I love to hear what the
people are saying. You see the smiles on the faces of the people who are coming.
They have been terrified even to go to church for a year now because dad is
acting a little different, so they bring them to this wonderful, safe
environment where there is entertainment and education. It's wholesome,
dementia-friendly, and he is smiling. Boy that does it for me. In the eight that
we have, those are the anecdotal results we are getting thus far.
The Chair: I think Dr. Molnar wanted to come in on this as
Dr. Molnar: On the question of evaluation, we need to be
careful because with health sciences research we find that if we try to evaluate
them just as they are being formed, or within the first year or two, they
invariably fail. They haven't crystalized, consolidated and found efficiencies
They go through at least three stages. The first is development
consolidation; at the second stage you can study process measures and try to
increase efficiencies; and at the third stage you look at outcomes on the people
and on the health care system.
The Ontario Ministry of Health is developing a dementia plan — we
met with them last week — through Cancer Care Ontario. They are doing a
large-scale, systemic review of dementia services and dementia bundles of care
from around the world. I have done systemic reviews, but this one will be
monstrous. It really takes Cancer Care Ontario resources. I would recommend
touching base with them when they get that in four to five months because that
will be incredibly valuable.
Once again, we will end up with gaps in the research. We will
need some faith to pick the best projects to get going so that they can be
consolidated and crystallized for a few years, and then we can study them. There
are still some gaps and nuances to the evaluation.
Senator Stewart Olsen: Thank you for your presentations.
They are very good. Of course, I am very interested in New Brunswick, as I am
I am a bit curious, Mr. McGeorge: What is the iPod project?
Mr. McGeorge: In my last pre-retirement job I was at York
Care Centre, where we set the organization up as a centre of excellence. We
established a research and development unit called the Atlantic Institute on
Aging. Through that process, we discovered the music and memory research project
being conducted by a researcher out of New York City. He was looking for some
By the way, if you google “Story of Henry” on YouTube, that will
tell you anything you ever needed to know. It's an amazing story of how music
unlocks the brain.
What they taught us was that music resides in a part of the brain
that is not affected by dementia, which is beautiful. With the iPod project, we
work with the families. We ask them, “What kind of music did dad like when he
was in his prime?” For example, they say, “He liked country and western.” So we
find some great Johnny Cash, or whatever, and download it to the iPod. When he
is feeling morose or agitated, we put the iPod on and pretty soon you see the
smile replacing the grimace. You see the eyes light up.
If you look at Henry Story, you will see this gentleman who had
been unresponsive for, I think, three years. Suddenly, his eyes are lighting up.
He is singing and clapping his hands. His feet are going, and he is starting to
talk after a while.
We have a donor in New Brunswick who is interested in broadening
that through the province. We now have a pilot going in Fredericton and the
donor has now said, “If you do real well, I will double my donation so you can
roll it out more broadly.”
Senator Stewart Olsen: On the broader outlook — and this
request is for both of you — this is a personal thing, but I am curious about
it. I am hearing about caregiver burnout and the difficulties in keeping people
at home, but I wonder about the creation of the Alzheimer communities and
dementia communities, where people can go and live and be cared for — and
perhaps they come home for weekends or something like that — and where they are
secure and stimulated. With the best intentions, families are usually not able
to keep up therapies. Mostly they're working. They come home and they're
exhausted, even if they have caregivers coming in. I think that might lead to
more fear in the patients, and more uneasiness. I'm wondering what you would
think of a stable community or a stable residence that is geared especially for
Mr. McGeorge: We actually have run, for the last nine
years, a symposium on Excellence in Aging in Fredericton. We have had speakers
from all over the world, except Dr. Molnar, who will be next. One of our
speakers last year was the director of a big facility just outside Amsterdam,
where in fact they have taken a city block and redesigned it as a dementia care
facility. Several people in our province have gotten pretty excited about that.
How you take those principles and adapt them is not clear. When I
was at my previous employment, York Care Centre, we used to say probably about
60 per cent of our people had dementia anyway. Our facility was rapidly becoming
a large dementia facility.
Dr. Bill Thomas, who is the founder of the Eden concept and
ChangingAging, is coming to the Atlantic provinces on a tour. He shocked the
news media in Fredericton when he was there a year ago by making the
pronouncement that we should stop building nursing homes. He was advocating what
you were just talking about, smaller dementia-friendly facilities. You're right;
the caregiver burnout is — I have lived it. We were there with our family; we
know it. It's not a foreign concept, and it's real. They can only take it for so
long before something has to happen.
Dr. Molnar: I think what you're highlighting is that we
need to invest more upstream — the more we can invest in a suite of respite
options. We have caregivers that are integrated into all of our committees now.
What they tell us is not one option; they want a whole suite of options that are
accessible in urban and rural settings. So this would be one of a suite of
upstream investments. That is critical to helping persons with dementia, their
families and hospitals. Once again, our hospitals are being crushed by this load
because they're a default care setting that they were never designed to be.
I would be very interested, when the Cancer Care Ontario review
comes out, the systematic review, whether that model is part of it and seeing
how much evidence they can dig up. They are investing a lot in that. Once again,
we do need to go back to the evidence. There is a lot of anecdotal information.
Anecdotes are a form of evidence, but you need to see how strong and consistent
the evidence is when you look at it in broader terms.
Senator Seidman: Thank you both very much. You have given
us an awful lot to chew on, as they say. In fact, I was going to ask both of you
what you see to be the essential elements of a national dementia strategy, as
that's what we keep hearing about. Perhaps both of you have to some extent given
a fairly good accounting of that already, but I would like to give you both the
opportunity to go beyond what you have already said to us and perhaps add. Then
I do have a couple more specific questions, if I might.
Dr. Molnar: Of the essential elements, number one would be
composition. Certainly the multiple partners are critical, including persons
with dementia, when and how they can participate; including caregivers;
including an urban and rural balance to ensure everybody is integrated;
including some underserved populations, such as the francophone population and
the First Nations populations that we don't serve adequately. So composition is
As I indicated before, I do think government needs to be
integrated into this. We need people who have the authority to make the hard
decisions, which includes shifting money within that fixed zero-sum pot. So
those are key.
Then we need a model of community verses acute care verses
long-term care so that we can outline all of the opportunities, all of the
evidence for different services within each of those areas within the journey
that people experience, and ensure that the people at the table represent all of
those elements in a balanced fashion. So we need to have proper representation
and proper authority to make the really hard decisions, because everyone is in
favour of these ideas until they realize it's their money that's being shifted.
We have all lived that, I'm certain.
Mr. McGeorge: To me, with a national dementia strategy,
once we get the organization set — and we could argue for a long time as to what
that organization ought to look like. By the way, to your earlier question, I do
think it needs to be close enough to government to be taken seriously but far
enough away not to be subject to political peaks and hollows, somehow.
In any event, the word that comes to my mind is a national
repository. Right now, the practices across the country are, frankly, all over
the map. We have been talking about polypharmacy in this country for, what, a
decade or more? I'm not sure where you go to get really good, honest-to-goodness
best practice information on that whole broad, complicated topic. I know
polypharmacy is alive and well in New Brunswick and not serving us all that
well, so a repository of best practice, a 1-800 number.
Jeffrey Simpson did us a great favour in his book Chronic
Condition. I bought copies for my board and made them read it a while ago.
He makes it very clear that our system, even as it currently exists, doesn't
perform anywhere nearly as well as Norway, Denmark, the Netherlands, Sweden,
Germany and Britain, and yet we spend more money doing it. So we need to get a
life and make some changes here.
So a repository for best practices and a sharp focus on research.
In New Brunswick, we're having some very active conversations with researchers
in universities in our province. They want to do research that is of interest to
them. We are saying, “No, it ought to be of interest to us and focused on what
is going to be delivering better care for our people.” So a sharp research
Standardized training. I like Dr. Molnar's notion of the
accreditation standards. That's pretty long overdue as it relates to dementia
care in health care facilities. So a base where things like that would be pulled
together. That would be it for me.
Senator Seidman: If I might, Mr. McGeorge, continue along
this pathway a bit, in your presentation about the importance of a strategy and
what would be flowing from a strategy, we talked about some sort of oversight.
So we have this model. How are we going to oversee it? Senator Eggleton asked
this question. I know our chair asks this question very often to witnesses who
are here: How are we going to oversee this?
What you say here is the proposed Canadian Alzheimer's disease
and dementia partnership is a model that could serve to advance the strategy
that is so necessary in providing the required leadership. Could you please
elaborate? You say it's modelled on the Canadian Partnership Against Cancer. You
gave that a great degree of relevance in your presentation. If you might explain
to us what that model is and how it could be used as a model for us in
coordinating and oversight, if I understand correctly.
Mr. McGeorge: I confess that I don't know as much about it
as I need to. I know that our national office, Mimi Lowi-Young and her
colleagues, are very much attuned to all of the national. The one thing that has
resonated with me — we've talked about it nationally — is let's not try to
reinvent wheels here. Let's use the principles that are already there with the
national cancer partnership. Quite frankly, I would have to confess that I don't
know a lot about that. All I know is it has worked.
Senator Seidman: That's fine.
Mr. McGeorge: The results have been absolutely phenomenal
Senator Seidman: That's something obviously for us to
The Chair: We have it on the record.
Senator Seidman: Okay, thank you.
Dr. Molnar, if I could ask you more specific information about
the Linda Lee clinics that you suggested were one model among many that would
need to be used, what is that model? Does it provide care and support to
informal caregivers? I won't use the word “informal” because we have been told
that that is not the preferred language. So to caregivers and individuals
affected by dementia, what supports are included for them in this clinic?
Dr. Molnar: There are now about 78 Linda Lee primary care
collaborative care memory clinics in Ontario. They are growing rapidly. There is
a long waiting list of family health teams to join.
Essentially, the way these come about is a family health team
will indicate their interest: one part of a large family health team or family
health organization, one team of one or two physicians, a nurse,
physiotherapist, occupational therapist, dietician, and their staff will
indicate a willingness to become these specialists within the larger family
health team. This can include dozens of physician practices. So they become the
Through Linda Lee's organization, they receive training at their
site on how do you perform dementia care, didactic teaching as well as Linda Lee
and her team coming and running clinics. There is a lot of on-site training that
goes on for how you diagnose and treat dementia, how you rule out co-morbidity.
Then they operate for a while, and Linda Lee will hold annual refresher days
It's still an evolving network. It hasn't reached a full network
status yet, but it's slowly becoming a network which will require central
Now these are champions. These are physicians and their teams who
really champion dementia care. The physicians earn less money by doing this than
they would by not doing this. So it's missing that part of sustainability.
Whenever we do that, things can become a bit rocky, but these are people who are
The Ministry of Health in Ontario is taking a long, hard look at
how do we create a stable infrastructure that encourages people to do this, be
part of this and remain within this.
So far, people have been very loyal to the model because they see
great value in it. I think because family physicians are primary care
practitioners, are generalists, they understand diabetes, chronic lung disease,
heart failure very well, and then they are able to help manage that person with
dementia as they are going through these different stages. So it's evolving into
not just dementia but more a dementia chronic care model.
Then they will call on specialists to review cases. Sometimes a
specialist will come down and actually see patients in the family health team;
sometimes they will send them to the specialist clinic. Cases that are hard to
diagnose or have multiple co-morbidities, it's a bit beyond what the team can
do. So we're slowly creating that collaborative care model. That's a
In terms of the stages of evaluation, it's still in the formative
stages. We're starting to look with the grant at the process outcomes. How
efficient is this? How can we make this more efficient?
Down the road, once we have a more stable model, we will have to
look at larger outcomes.
Senator Seidman: This is Ontario specific?
Dr. Molnar: This is Ontario specific, but other provinces
are looking at it, like people in Saskatchewan have indicated interest, people
in the Prairies, people in B.C. There is interest popping around the country.
Senator Raine: As a follow-up, who is Linda Lee? Is she a
Dr. Molnar: She is a primary care physician who works in
the Waterloo area.
Dr. Molnar: While she runs around the province to try to
make this happen, she has a thriving practice of her own,
Senator Raine: Sounds like it would be good for her to
come and give her experience.
I really appreciate the information we are being given.
Dr. McGeorge, first of all, could tell me the name of Jeffrey
Simpson's book? It sounds like it would be worth reading.
The Chair: It's based on our health accord report. The
2004 health accord has everything that is there, plus a number of things that
have just been brought up.
Senator Raine: Before my time.
One of the things that concern me is that we have heard from
other people that the shortage of caregivers working full-time is already there.
So when we go to some kind of standardization of their training — and I guess
I'm nervous that we might put roadblocks in the way of encouraging people who
are compassionate and wanting to do the work and enjoying this kind of care from
being hired even if they aren't trained.
So would there be a way to screen people who are suitable for the
work as a standard, and then have level one, level two and level three type of
training in place as they are working with people with dementia? I have in my
experience seen people with no training very quickly becoming very valuable
because of their compassion and their energy and their desire to work with
Mr. McGeorge: We certainly wouldn't want to scare people
away by coming out with an incredible set of educational requirements for work.
The home care level and the personal support care worker level in nursing homes
and other related institutional facilities, what you describe is job number one.
I used to say in the staff orientations that I used to do, if on
the first day that you come to work you're not fired up about coming here,
please don't come. You have to have it in your heart first. It's not rocket
science, but you have to teach people — which we don't do all that well in our
province — just a bit about the world that people with dementia live and work
in. It's different from the world that I live in. But it's not a six-month
course or a year-long course, it's pretty basic stuff. So a graduated level of
credentialing that does not scare people away.
The other element of the shortage is the inconsistency as you go
across the country in professionalism and compensation. Some people are still
paid minimum wage; other people are paid a competitive salary level and expected
to do the same job.
So you can't resolve that necessarily nationally, but you can
create a framework that provinces can start to use. Even in the Atlantic
provinces there are different patterns. It's really quite astounding that Nova
Scotia does a whole different thing than we do in New Brunswick, yet we're just
Senator Raine: The interesting thing today is of course
with webinars you can quickly spread these best practices and this
standardization across the country, but somebody has to organize it from the
centre. With a webinar situation, you can take your best trainer from British
Columbia and Alberta or New Brunswick and expose their ideas and experience to
everyone. Is that what you envision as the central role for the centralization
of this kind of training?
Mr. McGeorge: That would be one major role, making some
sense of education and making it user-friendly. It's knowledge transfer big
Dr. Molnar: There are a lot of lessons learned in terms of
training when one looks at the responsive behaviour services and how they
trained people. First of all, the training does start with a didactic training,
maybe distance training. We found a lot people don't actually integrate it into
their day-to-day practice unless they have a trainer or mentor come and help
them learn how to integrate this when you actually provide the care. We need
on-site integration mentorship for some of the higher-level functions and then
ongoing or recurrent training, because there is a fair bit of decay that happens
over time. Then finally access to someone with greater expertise at a moment's
notice when things are not going well.
So we have to be careful that we don't put too much reliance on
just one stage of the training process. It's lifelong process or career-long
Senator Raine: Especially as you say with responsive
behaviour training because that could suddenly be in front of you, and you
haven't been trained for it.
I have a question about the research. I was happy to hear you
talk about research being the need to be focused and responsible. When the
Arthritis Research Centre of Canada was being formed, I was on the board, and
they worked with people with arthritis to discuss how the research should be
structured. They came up with a slogan, which has been their driving mantra:
“Practical research for everyday living.” So whenever they are looking at
research grant applications, they always view it through that lens. It has been
very useful for the organization. It might be something you want to consider.
Dr. Molnar: Can I comment on that?
Senator Raine: Yes, please.
Dr. Molnar: I absolutely agree. There is another thing
that I think has been helpful. I do dementia and driving research, and I'm one
of the editors of the Canadian Medical Association’s fitness-to-drive
guidelines. What we found very useful there is we have had people from Transport
Canada and the provincial ministries of transportation help guide our research.
They are intimately aware of the research. They tell us what is needed, and then
we do it and integrate it into our guidelines.
Having some of the people, once again, who hold the purse strings
at the provincial level perhaps being involved in the research is something that
doesn't happen very often but would certainly help with the movement of pilot to
full-scale research, the implementation. I don't see that happening as often as
it needs to.
Senator Raine: Thank you.
Senator Merchant: We have talked about this over the
course of this study, but Dr. Molnar, you spoke about the need for universities,
for medical schools, to help guide their students and also to become interested
in gerontology, and also you spoke about government having a role to play in the
whole strategy about dementia.
Could you be a little more specific? When would this education of
young people who are interested in going into medicine begin? Would that begin
at the high school level when people from different professions go out and speak
with high school students? I know a lot of high schools have programs that send
young students out as part of their courses to work into old people's homes.
They choose the areas where they want to volunteer to have a volunteer aspect to
Is there a country or countries in the world that have been
successful in attracting more people to gerontology? How did they do it?
Dr. Molnar: I agree that it should start at the earliest
levels to create dementia-friendly communities so that our children actually
know a little bit about aging and about dementia and are comfortable with that,
and it should move all the way up.
It should certainly be better integrated into medical school. So
in medical school, 100 per cent of students are required to do pediatrics even
though only 2 per cent of them will practice pediatrics. I was required even
though I knew I was going into geriatrics. Medical schools do not require
rotations in geriatrics or seniors care, even though the vast majority of the
students will be providing seniors care. There is a disconnect between what
society needs and what is being provided. The decisions are being made on a
political basis, the strength of different specialties rather than on what
society needs. So that certainly needs to change.
Psychiatry has done a great job. They require that all of the
psychiatry residents do a geriatric psychiatry rotation, and that has really
brought a lot of people into geriatric psychiatry. That's a bit of a success
story. They can certainly use a lot more, but they have had great success.
It's not required that internal medicine residents go into
geriatrics. Many of them avoid it because it is not sort of a sexy area. It's an
area that can be challenging, that can really challenge them but can be very
So certainly I agree with you. You have to have the exposure
throughout, and you have to mandate it or at least make sure it's proportional
to societal need.
Has any country done this well? I'm not aware of that, but I
don't really know the educational systems in the other countries. When I was
here last time we discussed the U.K. having more geriatricians than the U.S.,
but those are very different specialties. They provide more primary care than we
Mr. McGeorge: Just to Dr. Molnar's point, it's kind of
interesting as I'm interacting with family doctors in Fredericton, and I'm
interacting with quite a few right now because I co-chair our provincial Council
on Aging, which is trying to find some provincial solutions to all of this,
doctor after doctor will tell me, “My practice has now become a geriatric
practice, not by design, but by happenstance,” which is interesting.
We were struggling with some of these educational issues when I
was at York Care Centre. We could never hire nurses to begin with, and so we
went to the university and sat down with the nursing faculty and said, “How
about introducing some required rotations?” They did that. We started getting
them at fourth year, then third year, then second year, then in the first year.
And we did do some evaluations of those rotations. Every rotation we did an
evaluation, and to a person the students would say, “I thought looking after old
folks when I came here was dull and boring, and I didn't want to come here.
Three weeks later I discovered it's fun, it's exciting, and it's not anything
like I expected it would be.” So we went from couldn't hire nurses to having a
waiting list, and we did that over just about a three-year period, which was
kind of cool.
We visited a geriatric centre in Boston in pursuit of some neat,
new ideas. Driving on the campus of this big centre we saw a soccer field,
basketball courts. We're thinking, “This is a geriatric centre? Soccer field,
basketball courts?” And this building over here, and they said, “Oh, yes, that's
our school. That's a full K to 12 school program. We believe in integrating our
elders with the kids from day one.”
In our environment in Fredericton we have been able to integrate
with several of our schools and get them thinking, and as a result of that, a
lot of kids have gone on to take gerontology in school. We haven't found any
geriatricians in that cohort yet, but we have attracted them to our environment
through a program that we call Narrative, which didn't force kids but encouraged
them to interact in a systemic way with families and elders. Through the iPod
project, we found the same thing. We got elementary and high school kids coming
in, interacting with families, and in the process they discover that old folks
aren't as weird as they thought we were, that it's really kind of nice. We have
developed that some way.
Senator Merchant: One thing that happens to people as they
age, because I have seen this with my parents, is they lose their doctors.
Sometimes their doctors were a bit older than they were when they started out,
and then suddenly the doctor that knows you best is gone. It's hard for you to
retrace all that memory if you find a new doctor to have a continuum. That is a
very difficult thing to face.
Dr. Molnar: I think the practice that we see occurring
more and more of primary care being brought together into family health teams,
and now Ontario is looking at larger networks, is the way to go because they can
do succession planning, the senior physicians, and I see this. They are starting
to recruit junior physicians who they find have the right attitude and skills
and they can integrate them slowly into their practice so that they'll be ready
to take over when the time comes. I think the days of the solo practice are
slowly being left behind, and that network practice may help address some of
this with succession planning.
Senator Merchant: You said there were certain communities
that were under-represented, and we know that; we have heard that before.
In the kind of plans that you make, some of these homes where you
say perhaps they should be more specialized to Alzheimer's people, will that be
something that is financially available to everyone? Is there an extra cost? I
am thinking about First Nations, for instance. Maybe some of the poorly
represented may not have access to some of these programs. Is there a cost? Is
there a difference in the cost for these sorts of systems?
Dr. Molnar: There will be a cost to not providing these
services. If we don't provide them, then we will provide for people in acute
care hospitals at $1,000 to $1,200 a day. It is a matter of shifting costs and
providing the right care in the right setting. People with dementia lose their
secondary and tertiary languages. They revert to their primary language, and
that's what you have to serve them in.
Senator Merchant: I didn't express myself well. Is there a
cost to the individuals?
Dr. Molnar: Residences are available at a high cost,
thousands of dollars per month. If people can't afford it, then they end up in
long-term care at a very high cost. We need more subsidized residences if we
want to save money and prevent hospitalizations, but we are not willing to shift
that money to the right places.
Senator Frum: Mr. McGeorge, when you were talking about
the iPod program, you spoke about the problem of overmedication. Could you speak
briefly on the problem of overmedication and the consequences of it? I presume
it is done mostly for the benefit of the caregivers, not necessarily the
patients. How does overmedication fit into a national strategy?
Mr. McGeorge: Since polypharmacy has been identified by
the CMA as one of the major issues in seniors care, clearly it needs to remain
there and be dealt with. It is well recognized as a chronic, long-standing
issue. There are many research papers and publications which clearly show that
too often drugs are the treatment of first resort rather than last resort.
This is interesting. We didn't set out to do this. We just wanted
to help people. We found a significant decrease in the need for sleeping
medication with the iPod project. We found a significant decrease in the need
for mood altering drugs, some of the psychotropic drugs. We also found better
appetite and improved cognition. We weren't expecting any of that. We were just
hoping for folks to be looked after better.
As part of a national dementia strategy, it would be my hope that
there would be a real focus on polypharmacy.
I was asking this question last week as we were having
discussions around our own council: Is there a clinical pharmacologist in the
province of New Brunswick? I don't believe there is. That would be a
pharmacologist with significant advanced training who would be the advance
trainer to clinicians, physicians and others. That is more Dr. Molnar's domain
than mine, but we recognize it as a serious public policy issue.
Dr. Molnar: We have to be careful in terms of how we use
the word “polypharmacy” because polypharmacy sometimes can be good. The
medications are keeping people alive. We see that sometimes when we stop the
medications and people pass away quickly. What we are talking about is
inappropriate polypharmacy. It is a huge problem. It is estimated that one third
of the admissions to hospital are related to medications, either taking them
inappropriately or double dosing. This is an even bigger problem with people
with dementia because people with dementia are exquisitely sensitive to these
medication errors and to the side effects of the medications. They might
tolerate the medications for many years, but once they develop dementia, they
develop all the cognitive side effects, all the delirium side effects of the
medications. It is a moving target. The overall prescriptions must change over
There are two problems occurring here. One is the silo focus we
apply when we are treating diseases. The cardiologist will use their
evidence-based slew of medications, the respirologists theirs, the geriatricians
theirs, and they don't mix. What we do not have now is integrated chronic
disease management, a platform where the specialists in a complex situation can
meet and iron things out. We need to get that integrated chronic disease
management, which is dementia-plus care.
The other is behaviour. People are not well-versed in how to
manage behaviour, so it is medication first rather than non-medication
approaches. Those are two contributors.
Deprescribing is not taught in medical schools. I have never been
taught how to wean a patient from a medication. If you wean them
inappropriately, people go into withdrawal and end up in hospital. You have to
slow down, decrease the dose, and stop things appropriately. That is poorly
taught across the board. Physicians are taught to prescribe, not deprescribe. It
is a huge education gap.
The resources are being built. A lot of provincial governments
are investing in this. There will be resources on the Web and more courses, but
we need drivers or levers and billing codes. We get paid to prescribe
medications, not to deprescribe medications. That will not happen.
We did this when there was a code for reporting people who were
not fit to drive. The reports went up, and the crashes went down. This is an
effective lever to manage behaviour. There are some unintended consequences
which must be managed.
There is an old expression which I will paraphrase incorrectly;
it takes 10 seconds to write a prescription and a million seconds to stop it.
You do need appropriate billing codes. Ultimately, those billing codes will save
money. They will save the cost of the drug and the cost of the admissions to
hospital. Once again, we need to make those investments.
The Chair: This discussion on the appropriate use of
medications in this area is one I was going to pursue. You have covered it very
well. It's obviously a critical area. I was concerned when, Mr. McGeorge, you
indicated there isn't a specialist on that issue in New Brunswick. We have been
asking this question about the various group housing situations, and so on. It's
a challenge. We haven't moved as far as we had hoped, even though we did our
report on the 2004 health accord. The issue of available electronic records to
make those interpretations, Dr. Molnar, is a real issue for us.
In Canada there is a difficulty in getting any innovation moving.
There is an inability of the federal system to motivate and achieve agreement of
the provinces to meet certain targets, to report effectively and to be held
accountable for those.
Let's suppose we had dementia identified as a specific category
of funding in a new accord, and some base funding was set out. The drive to
accountability that could be that there would be no increase to any province in
that category unless they showed that they have met certain criteria. That is,
they are rewarded. If they have met them, they would be rewarded with perhaps
increased funding based on some sort of system.
Dr. Molnar, I don't want to go through it in exhaustive detail,
but are there elements in that approach that you think might work in terms of
this kind of situation?
Dr. Molnar: Certainly if the things they are accountable
for are achievable, it wouldn't be pie in the sky.
The Chair: Right. Let us assume it is designed
Dr. Molnar: It could work if there is a trickle-down
effect to the provinces, the regional health authorities, the hospitals and to
the actual programs providing the care. Once again we have these great
innovations, but if they don't get down to the front lines, then it's hard to
The Chair: That could be one of the measures in terms of
rewards as well because the feds can't tell the provinces to trickle it down,
but they can reward if it meets those objectives. You think there might be
possibilities in this kind of area if appropriately developed?
Dr. Molnar: If appropriately developed, that's certainly a
lever to improve care.
The Chair: Mr. McGeorge, do you have any comment on that?
Mr. McGeorge: One of the markers, as an illustration,
might be another reduction of ALC admissions in hospitals. The progress is all
over the map across the country. I am aware of the some of the practices or
non-practices in some of the provinces that are ranked the poorest. As certain
as I am sitting here, the reason that we don't score well in New Brunswick is
that we have not made that our priority, and it should be a priority. It's not
rocket science. People overcomplicate it, and it really isn't.
The Chair: I just want to stick to the principle today. We
have a number of examples, but thank you for that.
The issue of remuneration has come up in a number of ways. Today
it has come up a couple of times. Dr. Molnar, the specific example is
remuneration for deprescribing as opposed to prescribing.
One of the major things we identified in our study of the whole
health accord is that the inflexibility in the remuneration system was a major
barrier to innovation and the ability to take a pilot project that had worked
well and move it forward because it simply didn't meet the established processes
for rewarding activity. In other words, clinical activity that is cooperative
can't be recognized under the billing systems. I don't want further comment on
that necessarily but to indicate that is an issue that has come up before us
many times as a key issue. We will attempt to identify that.
The question that I really wanted to ask you, Dr. Molnar — and I
want an overview from you, if you can — is we are not dealing in our study with
fundamental scientific and medical research into the issue of dementia — that
is, from the scientific point of view. However, what we are hearing throughout
this study is that there is increasingly a view that we should be able to detect
dementia long before visible signs occur, and second, that if early
identification could occur, then we could perhaps make much faster progress with
regard to staving off the onset of dementia and dealing with it much more
effectively with treatment.
From your perspective, from your viewing of the world out there,
do you think we are progressing in this area? Do you think the research
community is tackling this aspect of the health research area? Are you hopeful
that progress either is being made or that you can see, perhaps in the near
term, progress might well be made?
Dr. Molnar: To be honest, that's not my area of research
expertise, but I'll comment on it.
The Chair: I realize that you have a perspective on the
comment that is unique for us.
Mr. Moreau: I do attend conferences where they discuss
some of the research that's been going on. I think it is promising looking at
biomarkers, be they blood tests or tests of the cerebral spinal fluid or PET
scans. I think researchers are taking this seriously, and in the next decade or
two we will have some great breakthroughs so that we can predict who will
develop dementia and start to look at prevention of the disease. Yes, I think
they are taking it seriously and are making some great ground.
The Chair: Thank you very much. I know from your
background, but I wanted your perspective as opposed to the specialists'
Senator Eggleton: Dr. Molnar, you suggest that
Accreditation Canada should be asked to develop a required operating procedure
that ensures that every acute care hospital in Canada has a dementia, delirium
and behavioural management service in place, ideally supported by both geriatric
medicine and geriatric psychiatry.
Well, Accreditation Canada is a non-profit organization. It does
the accreditation for hospitals, but it is not compulsory. Is it widely
accepted? Is it accepted by all hospitals?
Dr. Molnar: I think Mr. McGeorge could probably speak to
that better than I could.
Mr. McGeorge: Pretty much most hospitals. While it is
voluntary, you don't get to train nurses, doctors and other people in a clinical
setting if you aren't accredited. There is some leverage there.
Senator Eggleton: That's what I am trying to determine:
How much leverage is there here? This could be quite useful.
Mr. McGeorge: Absolutely.
Senator Eggleton: All right. Perhaps it is also something
we could put in a future health accord? Maybe there is a possibility for it.
Maybe even from here, we could recommend it in this study.
Beyond that, Dr. Molnar, you said that many specialist clinics
that care for community-dwelling persons with dementia are slowly suffering the
death of a thousand cuts. Furthermore, downsizing and closing these clinics
predictably leads to hospital admissions for persons with dementia. I understand
that, but then you go on in the next paragraph to talk about all these new
clinics that are formed on the Linda Lee model — you said 78 in Ontario alone.
Then you mentioned the Health Links model as well.
Is this Linda Lee primary plus the Health Links making up for the
loss here, or is there a gap here somewhere that we still need to pay attention
My second question on this is what is the difference between the
Health Links model and the Linda Lee primary care collaborative memory clinic
Dr. Molnar: What is happening now, although it wasn't
designed that way, is exactly what we need. We need to shift from hospital-based
services, which are the specialist clinics that operate within a hospital
budget, to community-based services. That is where we all know health care needs
to go. It is not being done in a planned fashion. As hospitals' budgets are
getting cut, they are looking at ambulatory care as a soft area to cut. They
will start closing or shutting down these clinics.
The Linda Lee model is voluntary at the moment. It is not being
designed by the Ministry of Health, although the ministry will look at this. We
are not creating that infrastructure. The shift is happening organically, as
much as I hate to use that word. It is happening naturally as physicians realize
it has to happen. Are there gaps? Gaps may open up, unless the ministers of
health realize quickly that we need to build good infrastructure into these
In terms of Health Links versus Linda Lee, I always think of the
Kaiser Permanente Triangle. The primary care physicians would be the initial
care for people with dementia. The mid-level would be the Linda Lee clinics. You
are increasing the investments, so some money is required to continue to train
these teams. At the top might be the Health Links, where you have dedicated
money and staff to do intense case management, whatever that means, so that you
can keep the person safely at home and keep the caregiver safe. It is a matter
of escalating investments, not for everyone but for the people who absolutely
need it. We don't have those escalation plans in place for many areas of health
care, including dementia, so people, by default, end up in hospital.
Senator Eggleton: Health Links is another step up the
ladder. It is a little more costly and intensive.
Dr. Molnar: Yes, Health Links have not dedicated
themselves to dementia care.
Senator Eggleton: Is Health Links for more advanced cases?
Dr. Molnar: Health Links in Ontario was designed for the 5
per cent of patients who cost the most to the health care system. There is some
thinking out there that maybe it is not the top 5 per cent where you have the
most return on investment; it is the next 10 per cent below that. It is an
experiment that's ongoing.
Senator Eggleton: Thank you.
The Chair: I want to come back, Mr. McGeorge, to your
memory café experience. I was impressed when by coincidence I caught a piece on
the news that New Brunswick was pursuing this. I checked into it, and at that
point it was unique in Canada that you had come into the worldwide experience on
the memory café.
You have provided us with an excellent overview that answers a
lots of questions that I would have wanted to put to you.
You have several of these in New Brunswick. What is your
experience with communities when they say, “Well, we'd like to have one, too,”
or however it works. How difficult is it for them to get under way? Is the
accumulating experience in New Brunswick making it increasingly easy for the
next one to join into the program?
Mr. McGeorge: It's getting easier for sure, as the word
gets out. The irreducible minimum, though, for any of these in any of the
communities is can you find two or three wonderful volunteers — because it has
to be volunteer-driven — who really have a passion and a heart for people with
dementia. Once you find those two or three people, then they will attract three,
four or five other people with them as volunteers to make it happen. With our
manual, we do some basic training with them, and there is no reason why we
couldn't go into any community, if they have two or three wonderful volunteers,
and have it up and running in a month.
The Chair: In terms of population, what is the smallest
community in New Brunswick that currently has one?
Mr. McGeorge: Probably Plaster Rock. I think there is the
home of the world pond hockey tournament. The population may be 1,200 or 1,400,
or something like that at most.
The Chair: That's excellent.
Senator Eggleton: I see you have some pamphlets, and one
is the Salvation Army location. Is it mainly churches, church basements or
community centres that you put these in? Do you have many of them that would be
storefronts, like a regular coffee house might be?
Mr. McGeorge: To begin with, we have to find a place that
is rent free. We're not paying. Providing it rent free is a manifestation of the
heart you have for the issue. Churches are one source and schools are another.
We just opened one up in Saint John at the Loch Lomond Villa Wellness Centre. It
is a very futuristic geriatric long-term care centre. So we're doing one there
as a pilot. That is working very well and will not be a pilot for very long.
I am trying so think of some of the other locations.
Senator Eggleton: There are a variety of locations. Does
any one type of location work better than others? I guess it depends on how many
volunteers you have and who runs the program.
Mr. McGeorge: We started out thinking we shouldn't do them
at nursing homes because there might be a little bias, but we're getting over
that, too. We're about to open up one in the French peninsula, in a nursing home
location, so wherever.
The Chair: Thank you very much. This has been excellent.
Dr. Molnar, we are delighted that you were willing to come back
and speak to us from your personal point of view on this. We appreciate that
Mr. McGeorge, we were certainly looking forward to your testimony
here. As I said, I think there would have been a lot more questions had you not
provided us with such a nice summary of how you go about setting one up, which
answers a lot of the questions that we might have asked to begin with. But your
additional information has put the human character on it.
We clearly recognize that the study we have undertaken has taken
us into areas where we realize it's an enormously important issue for the
country and for the population as a whole.
When you leave, if you would continue to think about the question
that Senator Eggleton put to you at the outset, which gets into the business of
how we would recommend a government-involved process that could actually work,
which deals with the fact that we are a federation, we have a federal government,
we have the provinces and territories, and we know the difficulties. We don't
need any further advice on what the difficulties are. They are outlined in our
study on this area. However, the kind of model that you've touched on, and very
good advice today, would you think about that a bit more and if anything occurs
to you could you get it to us through the clerk? We would really appreciate it
because, in the end, that may be the most critical link in anything that we can
recommend as we go forward. It's one thing to think of all the things that are
needed in the strategy. It is quite another thing to translate that into a
vehicle that can actually deliver it within the complexity of a federated