At some point, it becomes crystal clear that the person with dementia requires a level of care that cannot be safely provided at home…and 24/7 paid caregivers are not the answer either. You do a quick internet search and are bombarded with advertisements and slick pictures of older adults drinking wine at what looks like a resort. You start investigating and the costs of these places hits you like a Taser.

AAAAAAAAAAAAHHHHHHHHHHHHHHHHHHH!!!!!!!!!

This post is going to help you cut through the BS. Pretty wallpaper, beautiful bedrooms, and a snazzy meditation room with aromatherapy and massage chairs are nice; however, if the direct-care staff are clueless about dementia care, none of these items mean anything.

Everyone always asks questions like, “what services are covered, how many meals, etc.” I am focusing on 5 critical questions that few family caregivers think to ask because they assume (wrongly) that these 5 areas are sufficiently addressed. Otherwise, it wouldn’t be a Memory Care Unit, right?  WRONG!!!!!!!!

One more thing: Question #1 should be asked of your tour guide and the unit manager. The remaining questions should also be asked of the direct care staff, out of earshot of management. If management will not allow you to talk to the direct care staff alone, RED FLAG.

Question 1: Tell me about the unit manager and staff. Please describe the education, experience, and training of the unit manager (or person in charge of the clinical day-to-day operations of the Memory Care Unit).  What are his/her credentials in regard to caring for someone with dementia?

Here is what you want to hear/see:

• RN with a minimum of a bachelor’s degree or someone with at least a graduate degree (master’s degree or higher) in an aging-related field. Examples of an aging-related field include social work, gerontology, and psychology of aging. A degree in administration is worthless and does not prepare anyone for the realities of working with people with dementia. Someone with a business degree but with years of hands-on caring experience may be different. The perspective of the person in charge affects the competence of the direct care staff. If the person in charge knows nothing about dementia, the direct care staff have no resource.

Other important follow-up questions:

• Are there RNs on site 24/7 or simply “accessible”? And what does “accessible” mean?
• What type of dementia training do the staff receive? If this is a Memory Care Unit in Alabama, you will hear the word, “DETA.” Memory Care staff working in Alabama and having direct resident contact are mandated by the Dementia Education and Training Act (DETA) to receive very specific dementia training. Unfortunately, the training materials are a bit outdated. The majority of the training materials were developed in 1997 and the site was last updated in 2008. So what started out as a good idea is instead creating a poorly informed work force. DON’T RELY ONLY ON DETA TRAINING. Ask, “what else?”
• Inquire about turnover and longevity of the direct-care staff.

NOTE: I sometimes get fussed at because of my emphasis on education and degrees. I know that a butthead with a PhD is still a butthead. I also recognize that there are intuitive and wonderful folks out there with zero formal training who seem to naturally know how to best care for people with dementia. Those “naturals” are rare. The best people I have seen have a combination of formal education and natural, intuitive abilities. Those people are the rock stars of Memory Care.

If your tour guide or someone in administration repeatedly states that they are more interested in experience than in education,  or the facility seems to employ a lot of “naturals,” this is a GIANT RED FLAG that maybe the credentials of the staff may need to be beefed up. 

Question 2: What is the ratio of direct care staff to residents?

• Lower is better; 1 to 5 is superior to 1: 8 or 1:10.
• Do ratios change on different shifts? Weekends versus weekdays?
• Does the facility use contract or agency staffing? If so, when?
• How are call-ins handled?
• Look for other indicators of staffing:
  • Cleanliness of the residents. Lack of urine odor does not mean clean. Look at their hair, faces, hands, fingernails, and clothing. The more residents you notice with unbrushed hair, eye boogers, unwashed/unshaved faces, dirty hands, ragged and dirty fingernails, and stained clothing…the more concerned you should be with daily care.
  • NOTE: if the excuse offered is, “They refused x care and we have to respect their wishes,” RED FLAG. Staff who make such a statement are demonstrating a lack of knowledge  about handling care-refusal behavior in a sensitive and dignified way. There are resources out there for this behavior…I know because I’ve published them. Including this blog.

How to handle care refusals around dressing, bathing, and medications; entering their reality; care refusals based on fear

• Interaction between staff and residents (are the staff sitting with residents, interacting with them? Or are the staff sitting/standing off to the side, interacting with each other?

Question 3: What are the day-to-day activities for Memory Care Residents?

• Meaningful activities slow down functional decline, harness energy, and provide enjoyment; very important outcomes  for persons with dementia whose outlets are limited by the disease. You want to know who develops the activities and implements them. Does the facility employ a legitimate recreational therapist? Or is the “activity person” a nursing assistant who fulfills this role because he or she is unable to physically complete direct care activities? Some people, even with minimal education and experience, can intuitively fulfill this role…but those people are rare. If the person answering this question gets huffy or annoyed, RED FLAG!
• Find out how the activities are personalized for each resident.
  • Men may not be interested in “feminine activities” like painting or arts & crafts.

Question 4: What happens when residents become more dependent on others for care?

• For persons needing help with eating, is there a smaller dining area with staff offering assistance or feeding?
• Ask about bowel and bladder training
  • Even if the person is incontinent, should still be placed on the toilet because the incontinence may be due to “holding it in.” Simply changing a brief, instead of assisting onto a toilet or bedside commode, may reinforce incontinence…and increase the risk for bladder infections.
• How much notice/assistance is provided if another level of care is needed?

Question 5: How are behaviors such as agitation, anger, aggression, and refusals handled? Do not only ask the person giving you the tour. Speak with staff…out of earshot of the administrator.

• “Distraction” and “redirection” are not enough. If this is the sum total of behavior management, RED FLAG and look for another place.
• Optimal responses would address prevention strategies. You may want to ask directly, “How do you PREVENT these behaviors?” If the response is, “These behaviors cannot be prevented,” walk out. Or direct them to this blog, because I have postings about this very topic (like the one about crankiness). This facility is not for your loved one with dementia.
• Pay attention to the physical environment, which can trigger many behaviors. Are the residents crowded around the one dining room table? Are TVs on in the background? Is music blaring from out of the rooms? If a particular resident is loud or vocalizing, how do staff intervene?
• Ask about how knowledge of individual preferences and triggers are shared between staff members (Are there formal meetings? A communication book?).
• Talk to the direct care staff about:
  • Knowledge of individual preferences and triggers
  • Knowing the difference between a “knee-jerk” refusal and a true exercise in autonomy
• Most importantly, read the contract to see if any of these behaviors result in an involuntary discharge or to a transfer to a geriatric psychiatric facility.

While this list is not exhaustive, it does cover some really important areas that come back to haunt family members one their loved one is transitioned to a Memory Care Unit.  This information is especially important if the person with dementia has a history of care refusal behavior, agitation, or other behaviors.

Sometimes families are tempted to downplay behaviors because they really like the facility and think that everything will be fine. This is unfair to everyone, especially the person with dementia. Better to have an honest conversation and be told that the facility may not be equipped to care for loved one, than to be faced with an involuntary discharge or an emergency transfer to a psychiatric hospital.

Have your own experiences? Please share. I’m interested in other’s perspectives about this topic, especially from care partners who have lived it.

Are you caring for someone with dementia and want more personal help with understanding the behaviors? Click here.

Categories: Care Partners Caregiving Dementia Placement

Tagged as: Alzheimer's Memory Care

Dr. Rita Jablonski

Rita Jablonski, PhD, CRNP, FAAN, FGSA is a nurse practitioner, researcher, tenured professor, and former family caregiver. Her research and practice involve all aspects of dementia management; she is best known for non-drug strategies to address dementia-related behaviors.