Dementia Care in Assisted Living Homes

Learn how memory care for people with dementia is different from regular assisted living for the elderly.

By Elaine K. Howley, ContributorAug. 21, 2019
This article is based on reporting that features expert sources including Eleonora Tornatore-MikeshDouglas Scharre, MDAndrew Shea
U.S. News & World Report
ALZHEIMER’S DISEASE AND dementia are becoming an increasingly big part of the health care conversation in America as the population ages and more people develop these cognitive ailments. The Centers for Disease Control and Prevention reports that about 5 million people are living with Alzheimer’s disease today, a figure that’s anticipated to nearly triple to 14 million by 2060.

For many people, once dementia has progressed to a certain level, they may need more care than family members can provide and may need to be placed in a long-term care facility – either an assisted living community or a nursing home.

Memory Care vs. Assisted Living

Within assisted living facilities, there’s enormous variety in types of programs and quality. Of the 30,000 or so assisted living facilities currently operating in the United States, some cater specifically to adults with cognitive deficits and may be labeled as memory care centers. These facilities may offer better care for seniors with Alzheimer’s or dementia than a traditional assisted living community that doesn’t specifically cater to patients with dementia. These memory care facilities typically provide 24-hour supervised care in a separate wing or floor of a residential facility that helps keep residents safer and prevents them from wandering out of the building and potentially into danger.

Because many people with Alzheimer’s and dementia essentially revert back to an earlier time in their life, these centers often try to provide outlets for people to express those needs in a healthy way. For example, women who raised children when they were younger may feel the need to engage in a mothering role, so some facilities set up a room with a crib and a doll, which residents can tend to when they feel agitated about missing a child. For some older men, going to work every day was their primary driver in life, so some facilities set up a desk and a phone that’s not plugged in so they can go through the motions of going to work when they feel the urge to engage with that previous self.

In some facilities, the hallways are painted like a roadway or park so that residents feel like they’re outside when they’re actually safely indoors. Other assisted living facilities go to great lengths to recreate the appearance of the resident’s former home to increase a sense of safety and familiarity. In short, there are many ways for different memory care facilities to cater to the needs of residents well – the key is finding a facility that offers three important components:

  • Extensive staff training.
  • A structured, patient-centered program.
  • Appropriate and engaging activities for residents.

Staff Training

In 2018, the Alzheimer’s Association released its Dementia Care Practice Recommendations document that outlines best practices for providing care for people living with dementia. These guidelines help put the patient at the center of the conversation with all things regarding long-term care with dementia and aim to help define what’s considered to be high-quality care for individuals with dementia. Because there’s so much variation in the market in how different facilities solve the riddle of appropriately caring for older adults with dementia, it can be tricky to know whether a specific facility is doing a good job of it.

She adds that the best dementia care programs train everyone who works at the facility, not just the clinicians or caregivers who are directly responsible for delivering dementia care. “It’s not just nursing staff or program and recreation staff, but the dietary staff, the housekeeping staff, the maintenance staff. The training needs to be across the board and universal for every employee from the top down.”

These individuals, while not directly involved perhaps with resident care, are likely to come into contact with dementia patients from time to time, and they need to know how to respond if a resident is confused or combative and needs assistance. “That interaction between staff and residents is really defining.” Tornatore-Mikesh says to look for a culture of inclusivity in training and support at any facility you might be considering for a loved one. Each facility solves the riddle of training its own way, but it’s important to ask whether and how staff are specifically trained to care for people with dementia.

Structured Programming and Support

What makes one assisted living facility better for a person with dementia than another often comes back to how the care for these individuals is structured. “What makes a good dementia program – in addition to the training – is all in the approach,” Tornatore-Mikesh says. For example, the facility should make an effort to understand who the patient really is – and was. And make sure to build aspects of their life into a tailored program that suits their needs and preferences. This person-centered understanding of what’s important to an individual can help them feel more at home, safer and better cared for.

For example, she says if someone was a musician earlier in their life, letting staff know that and working in references to music into conversations and playing music can help them feel more at home and better understood. A lot of what makes for good care of a person with dementia is understanding who that individual is and was.

Tornatore-Mikesh says the presence of a highly-structured program is a good sign that a facility will be able to provide quality care for a loved one with dementia. While it’s important that residents have the ability to make autonomous decisions as much as possible, providing a structured routine – breakfast at a certain time every day in the same room, followed by a social activity that lasts the same length of time each day, followed by exercise and so on – can help residents feel safer and less adrift. “Even the most demented resident may not know that at 10 a.m. they’re walking after breakfast. But they know something is going to happen,” and they will naturally head toward the room where these activities take place.

“Structure is critical. Some residents’ children will say, ‘My mom thinks that she’s getting better,’ after she gets used to the routine,” notes Tornatore-Mikesh. “We know it’s a progressive disease, and she’s not actually getting better, but the structure allows her to be more independent,” which provides an important sense of autonomy and self-control that may have been missing before.

Specialized Activities for Dementia Residents

Dr. Douglas Scharre, a neurologist at the Ohio State University Wexner Medical Center, says it’s important to carefully investigate how a particular facility treats and supports residents with dementia. “From a resident or a family point of view – what you want to look for in assisted living is do they have activities for cognitively impaired adults? A lot of assisted living is widely different – some are just pure memory care and pure dementia care. Those are fabulous facilities. But some are a mixture of elderly, from those who don’t want to cook to people with dementia.”

That’s a wide spectrum of needs and preferences. And it’s difficult to cater to all of those different needs and demands well.

Some facilities will “close off a doorway and lock a door on some little hallway and say, ‘This is our memory unit,‘ but they have no training,” Scharre says. “If you’re a consumer, what I would suggest is to look carefully at their activity program for the cognitively impaired. Brain stimulation increases quality of life,” and by and large, if people with dementia are active and engaged during the day, “they’re not up at night,” which is a time when some people with dementia have a tendency to wander or get hurt.

Activities specifically geared for people with dementia might include:

  • Socializing one-on-one through conversations or reading a book together.
  • Enjoying simple arts and crafts.
  • Listening to and talking about music, or singing or playing music together.
  • Working on puzzles.
  • Looking through photo books together and recalling fond memories.
  • Exercising – take a walk in nature or simply get outside for some fresh air.
  • Visiting with animals, such as therapy dogs brought in specifically to stimulate the sense of touch and a feeling of unconditional love.

Engaging in more than one activity at a time can also lead to good outcomes. For example, combining cognitively stimulating activities like putting together a puzzle or folding napkins while listening to music can help some people with dementia feel more grounded and focused.

No matter which specific activities are on offer, the Alzheimer’s Association reports that it’s important that interaction be done “with – not to or for – the resident,” so look for facilities that emphasize one-on-one caregiver to resident interaction and resident-to-resident social activities.

Scharre says that when it comes to cognition, there’s a very real “use it or lose it proposition,” so look for facilities that work hard to keep seniors with dementia actively engaged and challenged throughout the day, with an emphasis on socialization at a range of different levels in a structured environment.

Financing Dementia Care

As with all discussions of senior care options, cost becomes a factor when determining the best approach or placement for someone with dementia. Because most people who have dementia are older and likely on Medicare, it’s important for seniors and their families “to understand what kinds of dementia care Medicare does and doesn’t cover,” says Andrew Shea, vice president of eHealth Inc.’s Medicare sector. eHealth is a private, online health insurance exchange based in Santa Clara, California. Coverage levels can vary depending on the plan, the state you live in and how far the disease has progressed.

“In the earlier stages, when patients and their families are searching for answers, Medicare generally covers 80% of costs associated with diagnosis, after deductible,” Shea says. “Medicare Supplement plans can help fill that gap. There are also Medicare Advantage Special Needs Plans (SNPs) that are designed specifically for people with Alzheimer’s and will fill in some of the gaps as well.” In 2017, Medicare also began covering care planning for people who had a diagnosis to help families make arrangement for future treatment options. Counseling and physical or occupational therapy may also be covered “when these services are deemed medically necessary,” Shea says.

For people with dementia living in an assisted living facility, it’s also important to realize that Medicare doesn’t cover the cost of living in those facilities. “Generally speaking, Medicare will not cover long-term care for people with dementia or Alzheimer’s,” Shea says, meaning the room and board aspect of care. Qualified medical expenses related to the disease itself for other illnesses may be covered.

Similarly, there are limitations on what Medicare will pay for when a senior is living in a nursing home. “Nursing home care under Medicare is generally limited to 100 days and must follow a hospitalization. If the patient is certified homebound, Medicare will pay for 35 hours per week of home health care, but qualifying as ‘homebound’ can be tricky,” Shea says. And in the “last six months of life, Medicare will provide coverage for hospice care.” While many medically necessary procedures will be covered to some degree, “alternative treatments such as acupuncture and herbal remedies” are not covered by Medicare.

When a senior has spent down his or her reserves and can no longer cover the cost of living in a long-term care facility out of pocket or via private or long-term care insurance options, another federal health insurance program called Medicaid may kick in. That program “will provide coverage for long-term or in-home care in some cases, for those who qualify,” Shea says.

When medications are involved in treating dementia, a discussion of prescription coverage may also become part of the conversation. “Medicare Part D will cover a broad range of drugs used to treat Alzheimer’s and dementia but not all Part D plans cover the same drugs at the same cost. It’s important to discuss prescription options with a physician and make sure you’re enrolled in the Part D drug plan that’s best matched to your needs and budget,” Shea says. “For example, eHealth’s Medicare prescription drug coverage comparison tool found an average savings of $531 per year for Medicare consumers who switched to the plan that best covered their prescription drugs.”

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