Section 8

Dementia Care in Various Settings

Activities of Daily Living (ADLs)

and Instrumental Activities of Daily Living (IADLs) Issues and Tools of Measurement ; Determinants of those needing assisted living:

Performance of

    • Instrumental Activities of Daily Living (IADLs)
    • Activities of Daily Living (ADLs)
  • Cognitive status
    • Orientation, registration, attention and calculation, recall, language, judgment, and reasoning.
  • Mental and behavioral status
  • Physical health and medical status


Issues in the performance of ADLs (Activities of Daily Living) and IADLs (Instrumental Activities of Daily Living):
  • Is activity done
    • At the appropriate time?
    • At the appropriate place?
    • In the appropriate manner?
  • Time required for the activity
  • Difficulty with the performance of the activity
  • Changes in function over short periods of time.

Reasons for difficulties with ADLs and IADLs:
  • Physical impairments/problems
    • Reduced Range of Motion (ROM), stiffness, tremors, reduced sensation
    • Pain/discomfort
    • SOB (shortness of breath), weakness, lack of endurance
    • Gait/balance problems
    • Sensory impairments
    • Eating/Chewing problems
  • Cognitive limitations
    • Memory
    • Reasoning ability
    • Judgment
  • Emotional and behavioral factors
    • Fear, uncertainty, lack of confidence
    • Depression
    • Anxiety


Contextual factors in ADL and IADL function:
  • Personal preferences/decisions
    • Motivation
    • "Learned dependency"
    • Cultural factors
  • Family dynamics
  • Environmental fit
    • Barriers to accessibility
    • Features that increase risks
    • Lack of assistive technology

Tools for measuring physical function:
  • Katz Index of ADL (Activities of Daily Living)
    • Specifies some components of activity, but they are aggregated
    • Only indicates whether elder receives assistance - not the amount needed
    • Uses hierarchy to determine level of dependence
    • Good for predictive ability, not applicable for determining needed services
  • Functional Independence Measure (FIM)
    • Considers:
      • Time to accomplish activity
      • Need for assistive device
      • Need for cueing/coaxing
      • Approximate amount of activity person can do
    • Does not consider
      • Context - home, hospital, structured environment
      • Resistance - in cognitively impaired

Cognitive assessment tools:
  • Mini-Mental State Examination (MMS)
    • Advantages:
      • Relatively short
      • Well tested
      • Samples the domain of cognitive function relatively well (except for judgment)
    • Disadvantages:
      • Educational level may have effect
      • Vision or upper extremity disabilities may interfere (drawing and writing)

 

Problems with Measurement Tools:
  • Fail to measure interactions among various domains:
    • Examine only physical function or amount of assistance needed, not
      • Cognitive factors
      • Social or cultural factor
      • Contextual factors (environmental barriers)
    • Examine only cognitive, mood, or behavior status and do not link to physical function
Implications of limitations in tools:
  • Good interviewing skills are critical.
  • Acute observational skills are imperative.
  • Professional judgment is absolutely necessary.


Source: Dr. Linda Redford, Center on Aging, Kansas University Medical Center, at "Assisted Living Skills Training" sponsored by Nebraska Department of Health and Human Services, January 20, 1999.

Compiled by the Lincoln/Greater Nebraska Chapter of the Alzheimer's Association, 1999.

Assisted Living Fact Sheet

What is Assisted Living?
  • A residential setting
  • Promotes aging in place
  • Supportive, health-related services
  • Available 24-hours a day to meet unscheduled needs

Philosophy of Assisted Living
  • Helps people maintain their optimal autonomy and independence
  • Family-like environment
  • Homelike environment (such as personal furniture, privacy)
  • Strives to provide services in the way people are accustomed to

Assisted Living serves people who
  • Need help with housekeeping chores, meal preparation, bathing, dressing, or taking medications
  • Require some health care assistance or monitoring
  • Need transportation and mobility assistance or monitoring
  • Have periods of confusion or memory problems

Services provided
  • Skilled nursing - nurse delegation from own staff or outside staff
  • Meals Assistance with personal care activities
  • Help with medications
  • Transportation
  • Shopping
  • Housekeeping
  • Laundry

Characteristics to observe in Assisted Living Facilities
  • Staffing - inside or outside providers
  • Numbers per resident - staff ratios
  • Availability of licensed personnel - RN (registered nurse), LPN (license practical nurse)
  • Level of training of aides - certified medication aides
  • Supervisors of staff - licensed administrators

Staffing requirements for Assisted Living
  • Facility shall maintain a sufficient number of staff with the required training and skills necessary to meet the resident population's requirements for assistance or provision of personal care, ADL's (activities of daily living), health maintenance, supervision and other supportive services.
  • Facility shall have at least one staff person on the premises at all times when necessary to meet the needs of the residents.

Medication administration includes, but is not limited to:
  • Providing medications to another person according to the "Five Rights."
    • The right resident, the right drug, the right dosage, the right route, and the right time.
  • Recording medication provision.
  • Observing, monitoring, reporting and otherwise taking appropriate actions regarding desired effects, side effects, interactions, and contraindications associated with the medication.

Resident Service Agreements
  • Service plans and assessment must be very specific.
  • Services must reflect the findings of the assessment.
  • Services are congruent with those offered by the facility.
  • Level of care must be specified. (Is the level of care beyond the facility's ability?)

Observations related to Assisted Living services
  • Condition of residents
    • Clothing
      • Cleanliness
      • Fit
      • Appropriate to temperature - elderly tend to wear more clothing for warmth
    • Appearance
      • Hair cleaned and combed
      • Nails cleaned and trimmed
      • Skin - general condition
        • Dryness - alleviated by proper humidification in heating system
        • Lesions - possible diabetes, may lead to infection
        • Rash
        • "Bagginess" - possible weight loss
        • Bruises, cuts - note location, stage, pattern to determine abuse, neglect, or falling
  • Behavior of Residents
    • General demeanor
      • Smiling, laughing appropriately or sad, crying
      • Eye contact - may be cultural issue
      • Communication pattern
    • General comments
      • Pleased with care, food choices, privacy, staff, etc.
  • Recognizes and likes staff - calls them by name
    • Staff
    • Ratio of staff to residents is adequate to meet needs.
    • Appropriately trained staff are available to meet resident service needs.
    • Appropriate levels and numbers of staff are available at all times they may be needed.
    • Residents are receiving services from properly trained staff.
    • Appearance of staff
    • Visibility of staff in facility - Are staff clustered together, rather than with residents?
    • Responsiveness of staff to residents' calls.
    • Staff familiarity with residents
    • Manner in which staff address residents.
    • Manner in which staff discuss residents, especially "difficult" ones.
  • Condition of facility
    • Cleanliness, lack of clutter, lack of odors
    • Safety
    • Environment appropriate to needs of residents
    • Amenities available - telephone, assistive devices
    • Privacy available for resident
    • Homelike atmosphere (unless there are issues of safety)
      • Facility pets
      • Common Areas - set up to facilitate socialization, warm and comfortable

Source: Dr. Linda Redford, Center on Aging, Kansas University Medical Center, at "Assisted Living Skills Training" sponsored by Nebraska Department of Health and Human Services, January 20, 1999.

Compiled by the Lincoln/Greater Nebraska Chapter of the Alzheimer's Association, 1999.

Can an AD (Alzheimer's disease) Person Live Alone?

By Diana Wilson, M.A., Family Resources Coordinator, Alzheimer's Association. Courtesy of St. Louis Chapter.
Living day to day with Alzheimer's Disease requires a delicate balance between a person's independence and his or her safety. This balance is difficult to maintain when the AD (Alzheimer's Disease) person lives alone, and you, the caregiver, have to monitor the safety of this living arrangement.

Before making a change, caregivers need to first evaluate how well the AD (Alzheimer's Disease) individual handles daily tasks. It is important to directly observe the person performing these routine activities. Do not rely on the person's report, because it may not truly reflect the problem at hand.

Use the following questions to help determine how well the AD (Alzheimer's Disease) person is functioning independently and to identify safety concerns. One or more "Yes" answers in a category may indicate a need for more supervision, support or a change in living arrangements.


Safety Concerns

Does your loved one:
  • Have driving accidents, even minor ones? [ ] Yes [ ] No
  • Get lost driving or walking? [ ] Yes [ ] No
  • Burn pots on stove or forget to turn off burners or oven? [ ] Yes [ ] No
  • Forget to extinguish cigarettes? [ ] Yes [ ] No
  • Let strangers into the house or lock herself out often? [ ] Yes [ ] No
  • Forget to secure the house at night or when going out? [ ] Yes [ ] No
  • Demonstrate mood swings and suspicious or paranoid behaviors? [ ] Yes [ ] No

Personal Care

Is the person unable to:
  • Eat well-balanced meals and drink plenty of liquids? [ ] Yes [ ] No
  • Bathe and dress properly? [ ] Yes [ ] No
  • Use the bathroom when needed? [ ] Yes [ ] No

Other Tasks

Is the person unable to:
  • Keep up with housekeeping duties and home repairs? [ ] Yes [ ] No
  • Pay bills on time, balance checkbook and use credit cards? [ ] Yes [ ] No
  • Shop for, store and cook food correctly? [ ] Yes [ ] No
  • Use the phone, handle an answering machine and remember important
    phone numbers? [ ] Yes [ ] No
  • Take medication on time and in the right amount? [ ] Yes [ ] No
If your AD (Alzheimer's Disease) loved one passes the test in all three categories, remember to reevaluate on a frequent and regular basis. Any sudden changes in ability could indicate a potential health problem. Consult a health professional when necessary. If your loved one is having difficulty in one or more of these categories, it is time to consider making some changes to ensure safety. For more information on options available to you, please contact us at one of the phone numbers listed below. Together, we can discuss your situation and help determine what changes will be most beneficial to you and your loved one.


Compiled by the Lincoln/Greater Nebraska Chapter of the Alzheimer's Association, 1999.

Care Settings and How They Differ

Categories
Common
Names
Regulation
Staffing
(24-hour
awake)
Daily
Needs
Assistance
Activity
Program
Medication
Assistance
Funding
HOUSING ONLY

Retirement Housing

Senior Apartments

SeniorLiving

State:

Usually fire codes only

Usually do not have 24-hour staff on site

Usually no meals provided

May be able to pay privately to have someone come in and assist

Usually no organized activities

Usually no assistance provided

Private Funds

ROOM, BOARD
AND MINIMAL ASSISTANCE

Assisted Living

Board and Care

Group Home

Community Based Residential Facility

Foster Home
State:

Varies greatly from state to state

Some will have fire
code only, others regulate programs and services

May or may not have 24-hour awake staff

1 to 3 meals provided

Varied amount of care assistance available

Some structured activities

May have assistance available

Private Funds (most common)

Private Insurance

Medicaid Waivers (Not available in all states)

24-HOUR CARE WITH SKILLED NURSING SERVICES

Skilled Nursing Facility

Nursing Home

Health and Rehabilitation Center

Health Care Center

Hospice

State and/or Federal:

Regulations for all aspects (staffing numbers and qualifications, environment, activity programs, etc.)

Have 24-hour awake staff (usually offer 24-hour skilled care, too)

3 meals provided daily

Full assistance with care (when needed)

Have structured activity program

(Amounts and types vary)

Assistance provided

Private Funds

Medicaid

Private Insurance

Medicare (limited)

Compiled by the Lincoln/Greater Nebraska Chapter of the Alzheimer's Association, 1999.

Dementia Care Complaints and Concerns

  • Dementia in nursing facility residents is not carefully or accurately diagnosed, and sometimes is not diagnosed at all.
  • Acute and chronic illnesses, depression, and sensory impairments that can exacerbate cognitive impairment in an individual with dementia frequently are not diagnosed or treated.
  • There is a pervasive, general feeling among nursing facility administrators and staff that nothing can be done for dementia residents.
  • Nursing facility staff members frequently are not knowledgeable about dementia or effective methods of caring for residents with dementia. They generally are not aware of effective methods of responding to behavioral symptoms in dementia residents.
  • Psychotropic medications are used inappropriately for residents with dementia, particularly to control behavioral symptoms.
  • Physical restraints are used inappropriately for residents with dementia, particularly to control behavioral symptoms.
  • The basic needs of residents with dementia (such as hunger, thirst, and pain relief) may not be met because the individuals cannot identify or communicate their needs, and nursing facility staff members may not anticipate the needs.
  • The level of stimulation and noise in many nursing facilities is confusing for dementia residents.
  • Nursing facilities generally do not provide activities that are appropriate for residents with dementia.
  • Nursing facilities generally do not provide enough exercise and physical movement to meet the needs of dementia residents.
  • Nursing facilities do not provide enough continuity in staff and daily routines to meet the needs of residents with dementia.
  • Nursing facility staff members do not have enough time or flexibility to respond to the individual needs of dementia residents.
  • Nursing home staff members encourage dependency in residents with dementia by performing personal care functions, such as bathing and dressing, for them instead of allowing and assisting the residents to perform these functions themselves.
  • The physical environment of most nursing facilities is too "institutional" and not "homelike" enough for residents with dementia.
  • Most nursing facilities do not provide cues to help residents find their way.
  • Most nursing facilities do not provide appropriate space for residents to wander.
  • Most nursing facilities do not make use of design features that could support residents' independent functioning.
  • The needs of families of residents with dementia are not met in many nursing facilities.

Source: Office of Technology Assessment, 1992.

Compiled by the Lincoln/Greater Nebraska Chapter of the Alzheimer's Association, 1999.

Selecting a Dementia Care Unit

When selecting a dementia care unit, remember:

  • The primary goal of a dedicated dementia care unit is to help the patient achieve the best possible quality of life.
  • Care should be patient-centered, and offer residents
    • Safety
    • Security
    • Medical care
    • Emotional support
    • Reasonable privacy
    • Access to appropriate activities
    • Assistance with the activities of daily living
  • The state of Nebraska has not established uniform guidelines for dementia units. However, Nebraska does have a statute relating to the Alzheimer's Special Care Disclosure Act. Any facility which offers to provide care for persons with dementia/AD must disclose "the form of care or treatment provided that distinguishes such form as being especially applicable to or suitable for such persons." This disclosure is filed at the Department of Health and Human Services Regulation and Licensure office and is available for viewing by the public. The disclosed information explains the additional care provided in each of the following areas:
    • The special care unit's written statement of its overall philosophy and mission which reflects the needs of residents afflicted with Alzheimer's disease, dementia, or related disorder;
    • The process and criteria for placement in, transfer to, or discharge from the unit;
    • The process used for assessment and establishment of the plan of care and its implementation, including the method by which the plan of care evolves and is responsive to changes in condition;
    • Staff training and continuing education practices;
    • The physical environment and design features appropriate to support the functioning of cognitively impaired adult residents;
    • The frequency and types of resident activities;
    • The involvement of families and the availability of family support programs; and
    • The costs of care and any additional fees.
  • Families may find substantial differences in the units. In most cases, families have to rely on their own judgment when making their final selection.

Philosophy and Criteria for Admission to the Unit

One of the first things for a family to decide is if a dedicated special care dementia unit would be right for their loved one. A unit is only "special" if it offers a service that is "special" and needed by their family member. Pre-admission assessments should include the family's input regarding the patient's ability level. Management of difficult behaviors should be possible without the use of restraints. Matters like cost, unit security and medical services available may not seem important now, but will have long range importance to the family.
  • How does unit care differ from care in the regular facility?
    (Request written materials from the facility relative to philosophy of care, services provided for dementia patients and cost per day. Ask what this charge includes and are there additional costs?)
  • Does the unit accept Medicaid?
  • What is the unit's policy regarding medical and physical restraints?
    (Federal law requires that the facility use the least amount of medical and physical restraints possible to insure the resident's quality of life.)

  • How often does the staff monitor the necessary restraints?
  • What type of security system is used in the unit?
  • Are there special policies written for unit residents?
  • Are medical specialists available to serve residents in the unit?
    (For example, Dentist, Podiatrist, Ophthalmologist, Audiologist.)

  • Are skilled rehabilitation services available for unit residents?
    (For example, Physical, Occupational, Speech, Recreation.)
  • Can residents' private physicians be retained in the facility?
    (Federal law requires that a resident be seen by a physician every 30 days for the first three months. After this period of time, they must be seen by a physician every 60 days.)
  • Does the facility do a pre-admission assessment personally or by telephone?

Family Related Area

Residents in a unit need a familiar, secure environment. The value of having personal and treasured items in their rooms is important. The possibility of theft and breakage is present, but the worth of having these items far outweighs the disadvantages. Maintenance of family relationships with the resident and staff should be an important goal of the unit and facility.
  • Is the resident allowed personal items to furnish his/her room?
  • What is the policy on home visits outside the unit?
  • Is there a policy on family visits within the unit?
  • Is there a quiet, private area for residents to entertain visitors?

Services of the Facility

Staffing on units varies greatly. There should be enough staff on day and evening shifts so that residents can be assisted to do tasks for themselves rather than have the tasks done for them. Ongoing dementia behavior training is essential to the staff and residents. Activities are vital for a good unit. These activities should support remaining abilities, minimize failure, enhance dignity and enable pleasure. A beautiful environment does not necessarily insure quality care for the resident.
  • Is the environment clean (odor free), comfortable, and well lit?
  • How many people as staff are scheduled on each shift?
  • How is the staff selected and trained for the unit?
  • Is there an ongoing training program for staff working on the unit?
  • Do the residents seem to interact well with the staff?
  • Does the staff appear to display respect to the residents?
  • What is the availability of the beauty salon and barber shop for residents?
  • How often are snacks made available with finger food offered for self-feeding?
  • Are activity programs personalized to meet the needs of individual residents?
  • Who plans and carries out the activity programs and what are some examples of personalized actives?
  • What pharmacy does the nursing facility use?
  • Are unit residents included in social outings?
  • Is there a courtyard connected to the unit for the residents and how is it monitored?
  • Are the residents allowed to go out of the unit to take part in the facility's activities?
  • Is smoking allowed and is it supervised?

Tips for Families

Selecting a nursing facility for your loved one is a difficult procedure. Below are several tips you might want to consider before the final decision is made.
  • Make an appointment for a formal tour of the facility with the unit director.
  • Return to the facility at a different time of day and make an informal tour.
  • Consider the location of the facility in relationship to that of the family.
  • Talk to families with loved ones currently residing in the unit.
  • Check to see if your private physician will make calls to the facility you select. Find out if all pharmacy costs are billed directly to the family, or included in the monthly facility charges.
Telephone numbers to know:
  • (402) 471-2306, Nebraska Long-Term Care Ombudsman, advocate for nursing facility residents.
  • (402) 595-3356, Nebraska Department of Social Services - answers questions on Medicaid and spousal impoverishment.

 Source material: "Selecting a Nursing Home with a Dedicated Dementia Care Unit," by Nancy L. Mace, M.A., and Lisa P. Gwyther, A.C.S.W.

Compiled by the Lincoln/Greater Nebraska Chapter of the Alzheimer's Association, 1999.

Hospice Fact Sheet

Courtesy of Hospice Care of Nebraska

Hospice Is…

  • A philosophy of care dedicated to caring for individuals with life-limiting illness and their family.
  • Based on the holistic view of addressing palliative (Pain/symptom control) care with regard to physical, spiritual and emotional support.
  • A care alternative that emphasizes the quality of life.
  • An opportunity to spend as much remaining time in the comfort of home as possible, realizing the benefits and limitations to home care.
  • A chance to utilize the approach of an interdisciplinary team for support.
  • Maintaining the ability to make decisions that allow as much "normalcy" as possible.
  • A home-centered program regardless where patients live (whether it be home or nursing facility).

How Hospice Works…

  • Referrals may come from physicians, nurses, family members or patients themselves.
  • Hospice care is ordered by and managed by the patient's attending physician.
  • A plan of care is implemented and centered on support garnered by an interdisciplinary team with the most important member being the patient, with the extent of team involvement being determined by the patient. The interdisciplinary team includes:
    • A nurse visits intermittently to provide skilled assessment and to act as a liaison to the primary physician.
    • A social worker to provide resource information and emotional support.
    • A home health aide to assist with personal care.
    • A minister to provide spiritual care if requested, and is also available as a liaison to the patient's primary minister.
    • A dietitian to assist with nutritional counseling.
    • A pharmacist to provide information concerning medications.
    • A homemaker to assist with light housekeeping tasks.
    • A volunteer coordinator to implement volunteer services including transportation, respite and child care.
    • Therapists who can assess and provide physical, occupational and speech therapy.
    • A program coordinator to provide follow-up to the family unit after the death of the patient.
Hospice often draws families together to care for a loved one. It can assist in enhancing a relationship or to assist in preparing families for the "final good-bye."

Compiled by the Lincoln/Greater Nebraska Chapter of the Alzheimer's Association, 1999.

Qualities Necessary in an Assisted Living Facility

Qualities Necessary in an Assisted Living Facility for Individuals with Alzheimer's Disease and Related Disorders

When a facility says it is "dementia-capable," it is assumed the facility understands the needs of such individuals and can meet the needs of such an individual before it commits to her/his admission. Then retention/discharge issues become easier to deal with because both the facility and the resident (and family) know what the individual's needs are and the capacity of the facility to meet such needs.

The facility should provide:
  • A written statement of its mission, policies and procedures, reflecting how the setting can meet the specialized needs of individuals with dementia.
  • An initial screening of the applicant to determine the setting's ability to meet the anticipated needs of a person with dementia, prior to move-in and/or the execution of a resident agreement.
  • A more complete assessment of the resident and a written service plan using information from the assessment consistent with the services provided by the facility after move-in.
  • An individualized service plan developed with the resident as a full partner.
  • A safe and secure outdoor area for residents that wander.
  • Available staff to walk with individuals with unsteady gait.
  • Facility lighting that is even and consistent to help eliminate falls.
  • Meaningful activities which enhance the individual's positive self-image and sense of fulfillment, as well as allow for the individual's cognitive deficiencies. The activities should be appropriate for an adult and provide a feeling of satisfaction, enjoyment and accomplishment.
  • Safe floor surfaces and available handrails for support.
  • Clear paths to all destinations and sufficient cues and landmarks for identification of destinations (especially bathrooms).
  • A method that allows the resident to identify his/her room to help keep confusion to a minimum.
  • The opportunity for the resident to bring their personal belongings into the facility.
  • Access to the secure/safe outdoor area and windows to view the outside environment.
  • Availability of small private places for the family to meet with the resident.
  • The opportunity for the family to be involved in the resident's care plan.
  • Common use areas that are safe with appropriate seating.
  • The opportunity for the individual to be involved in decision-making as much as it is possible.
  • Available 24-hour awake staff.
  • Ongoing training to all appropriate staff on Alzheimer's disease and dementia care (i.e., wandering/egress control, general overview of Alzheimer's disease and related dementias, communication basics, creating a therapeutic environment, activity-focused care and dealing with difficult behaviors.)

Compiled by the Lincoln/Greater Nebraska Chapter of the Alzheimer's Association, 1999.

Suggested Criteria for Admission

of an Individual with Alzheimer's Disease or a Related Disorder to an Assisted Living Facility*

  1. Before admission to the facility, a total medical assessment of the individual must be completed. This assessment will include a functional checklist of the resident's activities of daily living (ADLs).
  2. Healthcare and financial durable power of attorney has been established or a conservator and guardian has been appointed for the individual with dementia. Advance medical directives for the individual are also established.
  3. Individual's every day function is affected by:
    • Short-term memory loss.
    • Disorientation to time, place and date.
    • An increase in poor/decreased judgment and problems with abstract thinking.
    • Unable to handle personal finances that result in making inappropriate financial decisions.
    • Difficulties communicating his/her immediate needs to the proper individuals. (i.e., family members or caregivers).
    • Inappropriate telephone usage which may include continually calling 911 for emergencies that do not exist.
    • The individual suffers from erratic sleep patterns.
    • The individual is wandering and getting lost.
    • The individual is suffering from sundowning (agitation and nervousness at sundown).
  4. The individual is demonstrating an inability to properly perform activities of daily living (ADLs) independently and assistance is required with more than one (bathing, dressing/grooming, toileting, continence mobility, eating).
  5. The individual does not have aggressive behaviors or "other" behaviors, which present a risk to the health and safety of the other residents in the facility. The "dementia-capable" facility to which an individual is referred has an appropriately trained staff and environment that can accommodate aggressive behaviors that do not present such risks. (Disruptive behaviors need to be assessed.)
  6. The individual must be ambulatory. If there is a history of continual falls, this must be noted and the frequency of these falls assessed.
  7. The individual's medical health is stable and preexisting conditions noted.
  8. The individual is able to communicate his/her needs to others in an appropriate manner.
*These suggested criteria apply to assisted living facilities that provide dementia-capable and NOT dementia-specific care.


Compiled by the Lincoln/Greater Nebraska Chapter of the Alzheimer's Association, 1999.

Suggested Criteria for Dismissal

of an Individual with Alzheimer's Disease or Related Disorders from an Assisted Living Facility*

  1. A medical condition requiring skilled nursing care. This includes specialized nursing procedures that can not be performed in an assisted living facility.
    • Bedridden for 14 days or more
    • Stage III and IV pressure sores
    • Needs 24-hour skilled care for an extended period
    • A physician's order to move the individual to more skilled care
  2. Diminished functional abilities that prohibit the individual from living in an assisted living facility at an appropriate level.
    • Unable to initiate activities of daily living (ADLs) without total assistance
      (such as bathing, dressing/grooming, toileting, continence mobility, eating)
    • Thought processing is severely impaired
    • The inability to communicate complicates pre-existing medical conditions
  3. Behavior symptoms develop that pose a danger to the individual or the welfare of others. The setting has attempted to make a reasonable accommodation without success to address resident behavior in ways that would make move-out or change unnecessary. This should all be documented in the resident's records.
    • Aggressive behaviors and physical and verbal abuse by an individual changes so that they pose a danger to the individuals or others or go beyond the capacity of the facility to make reasonable accommodations and therefore become unmanageable for the facility.
    • The facility institutes plans and staffing to deal with wandering and is no longer capable of accommodating an individual's wandering. As a result, there is danger to the individual and others.
  4. Pattern of non-compliance of care established.
*These suggested criteria apply to assisted living facilities that provide dementia-capable and NOT dementia-specific care.


Compiled by the Lincoln/Greater Nebraska Chapter of the Alzheimer's Association, 1999.

Training Requirements for Nurses Working with Dementia Patients

As a minimum, training for nurses should include:

  • Introduction to aging focusing on both biological and psychological factors. Content should include discussion of normal aging, theories, psychosocial aspects of aging, age-associated losses and reactions to loss, and ethnic/cultural issues.
  • Cognitive functioning in the aged. Normal cognitive function should be contrasted with abnormal functioning and progression of the disease process, and physiological changes associated with dementia. Accompanying reasons for corresponding cognitive deficits should be discussed, as should changes associated with reversible and irreversible dementias. Nurses should also be trained in the use, scoring, and interpretation of various assessment tools to measure cognitive function.
  • Behavior and nursing care problems such as dressing, bathing, and grooming; problems with incontinence, immobility, and eating; and assessment and identification of concomitant diseases and disorders. Nurses should be provided with techniques and interventions regarding behavior problems such as catastrophic behaviors, wandering, withdrawal, depression, nighttime restlessness, agitation, and combativeness.
  • Use of psychotropic drugs, including an in-depth discussion of types of medications, their appropriate use, and side effects. Nurses should be trained to identify both the need for a particular drug and inappropriate prescribing. Side effects (especially of neuroleptics) should be outlined and alternative therapies discussed.
  • Environmental restructuring, including the need for structure, consistency, and modified stimuli. Methods for providing a safe and secure environment should be set forth.
  • Social and emotional aspects of dementia, including the role of the nurse in providing support for the family and the dementia patient. Interventions, community resources, hospice and institutionalization should be discussed, as should possible reactions of the patient and the family members to various care options. Training should include an understanding of how best to obtain information about the social support network and social history of the patient and should provide knowledge regarding ways to facilitate continuity of care among various levels of care (from the home to the hospital or long-term care facility).
  • Methods for recognizing and preventing excess disability, including the causes of excess disability - fatigue, physical causes (pain, illness), medications, change in environment or caregiver, stressors, sensory impairment, and psychological factors such as depression. Alternatives to the use of physical and chemical restraints should be included.
  • Methods for training, supervising and evaluating nursing assistants in care of dementia patients.

Source: Advisory Panel on Alzheimer's Disease. Second Report of the Advisory Panel on Alzheimer's Disease: Appendix B. Department of Health and Human Services (DHHS) Publication Number (ADM) 91-1791. Washington, DC: Superintendent of Documents, U.S. Government Printing Office, 1991.

Compiled by the Lincoln/Greater Nebraska Chapter of the Alzheimer's Association, 1999.

Training Requirements for Nursing Assistants Working with Dementia Patients

All curricula for nursing assistants should include:

  • A basic overview of normal and abnormal aging. Content should compare and contrast normal age associated memory changes and abnormal changes associated with dementia and discuss stereotypes and myths of aging and general principles to utilize when working with the elderly.
  • Overview of Alzheimer's disease and other dementias, including theories of the cause(s) of ADRD (Alzheimer's disease and related dementias) as well as those related to cure. The pathophysiology and medical diagnosis of ADRD (Alzheimer's disease and related dementias) should be discussed simply and briefly.
  • Overview of symptoms of Alzheimer's disease and related dementias and methods to treat these symptoms. Symptoms to be discussed should include, but not be limited to, depression, anxiety, sleeplessness, incontinence, and misinterpretation of external stimuli.
  • Management of difficult behaviors through:
    • Use of communication skills in dementia patient management. This includes use of short simple sentences, eye contact, physical and verbal cues, and touch. Techniques to assist the aide in handling patient preservation (repetitive requests and actions) should be taught.
    • Prevention of and treatment for catastrophic reactions, agitation, hallucinations, and paranoia. Techniques, such as touch distraction and use of logs to record possible precipitating causes should be provided. The relationship between physical problems and behavioral problems should be noted.
    • Examination of causes of and interventions for care problems such as wandering, eating problems, bathing and grooming problems, and sleep difficulties.
    • Discussion of chemical and physical restraint use, including detrimental effects of both types of restraints and the need to develop more humane nursing interventions. Detrimental effects of physical restraints include psychological trauma, restlessness, dependency in ambulation, and potential for injury. Detrimental effects of chemical restraints include increased falling, extrapyramidal and anticholinergic reactions, tardive dyskinesia, and sedation as well as the tendency of caregivers to neglect the needs of a chemically sedated patient.
  • Safety measures. Because of poor judgment, dementia patients may attempt to drink poisons, misuse objects such as knives or scissors, or place themselves in dangerous positions. Nursing assistants working in long-term care facilities should learn of common hazards (such as shampoo, cleaning supplies, silverware) in the facility and learn techniques to alleviate those dangers. Home/health aides must become aware of safety hazards in the home, such as kitchen utensils and stoves, and learn creative ways to eliminate any danger to the patient.
  • Prevention and treatment of excess disability, including understanding of the causes of excess disability - fatigue, physical causes (pain, illness), medications, change in environment or caregiver, stressors, sensory impairment, and psychological factors such as depression. Methods to avoid and/or eliminate these factors should be emphasized.
  • Emotional and psychological aspects of Alzheimer's disease, including patient and family response to the disorder. Training should cover the losses felt by both patient and family and the distress resultant from those losses.
  • Respite care and self-care. Caring for a person with dementia can be emotionally and physically draining, and the nursing assistant must be trained in methods for reducing stress and burnout and dealing with feelings of guilt.

Source: Advisory Panel on Alzheimer's Disease. Second Report of the Advisory Panel on Alzheimer's Disease: Appendix A. Department of Health and Human Services (DHHS) Publication Number (ADM) 91-1791. Washington, DC: Superintendent of Documents., U.S. Government Printing Office, 1991.

Compiled by the Lincoln/Greater Nebraska Chapter of the Alzheimer's Association, 1999.

Training Requirements for Social Workers Working with Dementia Patients

As a minimum, training for social workers should include:

  • An overview of Alzheimer's disease and related dementias, including an overview of normal versus abnormal aging and a description of common problems associated with these diseases.
  • Common feelings and behaviors experienced by the dementia patient. An in-depth discussion of interventions to manage these feelings and behaviors should be provided.
  • Common feelings of family members. Methods to support the family including counseling techniques and the development and implementation of support groups should be provided.
  • Support for family (informal), professional, and paraprofessional dementia patient caregivers, including interventions to manage burnout and the frustration resulting from working with the dementia patient.
  • An overview of community and financial resources (such as Medicaid and Medicare) available to dementia patients and a discussion of care alternatives - respite care, day care, hospice and institutionalization.
  • Anticipation of and preparation for legal problems, including wills, trusts, guardianships, conservatorships, and powers of attorney.
Source: Advisory Panel on Alzheimer's Disease. Second Report of the Advisory Panel on Alzheimer's Disease: Appendix C. (Department of Health and Human Services (DHHS) Publication Number (ADM) 91-1791. Washington, DC: Superintendent of Documents, U.S. Government Printing Office, 1991.

Compiled by the Lincoln/Greater Nebraska Chapter of the Alzheimer's Association, 1999.