One of the biggest issues facing health care nationwide, especially in Maine where our population is much older than average, is geriatric psychiatry.

As people age, they are increasingly likely to develop dementia. At 65, 11 percent of people have dementia. At 85, about a third of people have Alzheimer's disease or some other form of dementia, according to the Alzheimer's Association.

People with dementia are often unable to understand what is happening around them. They may become frightened, belligerent, yell, scream, refuse to take their medications and even strike out at their caregivers.

When their caregivers run out of options, these patients show up at the emergency department.

Unfortunately, our treatment options are limited. We can medicate them, and in a worst-case scenario we may even try to send them to the state's only geriatric psychiatric facility, Pavilion 6 at Maine Medical Center, more commonly known as P-6.

In reality, while medication may temporarily keep them calm, it is not a long-term solution and while P-6 offers excellent care, at any given time it may have a waiting list a month long. To make matters worse, moving a person with dementia to unfamiliar settings only makes them more disoriented and confused.

There's more. Nationally, the number of people with Alzheimer's is expected to double in the next 35 years but in Lincoln County, and in much of coastal Maine, where our population is aging much more quickly than the rest of the nation, dementia is not only a bigger problem now, it is also growing more rapidly.

To sum things up, dementia is a real problem, it is getting worse nationally, and there are few if any good medical therapies available to us.

So, how do we prepare for a problem that has no medical cure and is expected to double in the next few decades? The emergency department is not the answer, and neither is P-6.

What we do have are strategies that not only make people with dementia more manageable but also greatly improve their quality of life.

Those strategies are sometimes called individualized care, and if that sounds non-clinical, there's a reason: what works best for people with dementia has a lot more to do with their environment, and in particular their relationships, than anything we can offer medically.

Individualized care is what happens when a group of people who know a patient, ideally the primary care physician, family members and caregivers, sit down and pool their knowledge to come up with a plan that caregivers can put into action.

It looks something like this: If a former night watchman wants to stay up all night and eat dinner at 8 a.m., as he did for the last thirty years of his career, that's fine. If a dairy farmer likes to rearrange the chairs in the common area every evening at about 6 p.m. as if he were herding his Holsteins, that's OK too.
Whenever possible, the same staff members work with a patient every day so they have a chance to learn their likes and dislikes and avoid the issues that can lead to an outburst. When it is done right, it makes the long-term care facility feel less scary and more comfortable and homelike.

While that all sounds like common sense, it isn't easy. It works best in places where a resident is still connected to the community, where his or her family can still come and visit on a regular basis, where the staff at the facility knows enough about him or her to put their actions into context.

Recently, we had a patient in our emergency department who was a resident of a nursing facility and had threatened staff and assaulted another patient.

When she arrived, she was very agitated and angry. Her behavior placed both her and her caregivers at risk, so we gave her medication that helped her calm down. There were no beds available at P-6 and we knew that if we admitted her to a hospital, she would become even more confused and agitated, and would require even more medication to calm her down.

But because the woman was living in a nursing facility that was in her own community, we were able to arrange a meeting with family and friends as well as her primary care physician, who had known her for many years.

What came out of that meeting was a care plan that helped manage her confusion without over-medicating her.

It revolved around activities - keeping her busy and giving her an outlet for her energy - and using the relationships that staff had developed with her to make her life more comfortable and predictable.

It worked because we were able to treat this woman in an environment that was familiar to her, and was a part of a caring community.

As an emergency physician who has worked in both large urban medical centers and in small rural hospitals, I can tell you that while large specialized facilities can offer the highly technical and advanced medical care that saves lives, the kind of care that improves quality of life is almost always better close to home.

Finding the balance between life-saving care and care that improves quality of life is one of the big challenges that face medical facilities of every size. As we live longer, health issues like dementia will continue to become bigger challenges for all of us. We will need to not only change the way our health care system functions, we will need to change the way we care for one another as a community.

Mark Fourre, MD, is an emergency physician and Chief Medical Officer of Lincoln County Healthcare, the parent company of Miles Memorial Hospital and St. Andrews Hospital. He also serves on Lincoln County Healthcare's Board of Trustees. Prior to joining Lincoln County Healthcare, Dr. Fourre was attending faculty at Maine Medical Center, where he developed the Emergency Medicine Residency Program and served as Residency Director.