What a Geriatrician Looks for in Memory Care

"Memory care" facilities in America are strange and unique phenomena. They have no true counterparts in most other advanced economies. Many other nations, for example, facilitate community-based dementia care in smaller cohorts. Some have even innovated through building dementia-focused communities, the best known of which is the Hogeweyk Dementia Village in the Netherlands. By contrast, in the United States, the concept of "memory care facilities" is strongly linked to the growth of assisted living. While some people living with dementia reside in long-term skilled nursing facilities (SNFs), such facilities are often a last resort for patients and families, as they nearly universally look and feel like hospitals. In most states, memory care units are embedded within assisted living facilities (ALFs), which are in turn regulated by state, rather than federal, entities.

Unlike many SNFs, ALFs are purposefully designed to look and feel like residential communities. ALF's architecture and interior design are often pleasant and engaging. This is, of course, a good thing. Behind the façade, however, there is a fundamental tension in many ALF-associated models for memory care. As residential communities, memory care units in ALFs are often home to residents living with dementia who have profound needs, both in medical and in personal care. Yet licensing and regulatory requirements in many states often fail to match these needs. As a result, facility-based memory care often suffers from understaffing, inadequate training, and subpar access to licensed physicians and skilled nurses.

As an example, you can peruse the Virginia regulations here.

The mismatch between substantial care needs and the services that memory care units are capable of providing makes it challenging for families to navigate their options. As a geriatrician, I have assisted hundreds of patients and families in this process. The most common question I receive is: "How do I know how to choose the right memory care environment?" It is always important to individualize major decisions like these, and there are no singular, definitive answers to this question well-suited to all people and all circumstances. But sometimes the best answer to a question is to pose a related set of essential questions. Throughout my journey in geriatrics care, here are four high-yield questions to ask:

Is a memory care unit the right thing?

If you or a loved one are already searching for a memory care unit, this might seem like a redundant question to ask. Yet oftentimes the services that someone living with dementia most needs can be better (and even less expensively) supplied in the existing home environment than in a memory care unit. This is in part because many of us have outsized expectations of what a memory care unit can, in fact, provide. It is also sometimes because we have undersized conceptions of how much we can, on the other hand, do in the home.

I have seen some patients leave home and thrive in a memory unit environment. I've seen others languish in memory care, with all parties wishing they'd tried more or longer in the home setting. We must ask ourselves: what are the particular needs of our loved one, and what are the particular needs of the caring family? Can we be confident that a memory care environment will well serve both the needs of the care receiver and of the caregivers? For example: an extroverted and active person living with dementia, who thankfully does not experience agitation or anxiety around others, might flourish in a communal environment. On the other hand, an introverted person with dementia who is prone to anxiety might find such a space overwhelming.

What is staffing like in the memory care unit, and in the ALF of which it is a part?

While many states have minimum standards, there is substantial variation across ALFs in the extent of staffing and in the training and qualifications of various team members. For example, many if not most team members in ALFs and memory care units are credentialed as certified nursing assistants (CNAs). CNA certification can be achieved with as little as 75 hours of total training. Many experienced CNAs are outstanding, but some may yet lack real-world proficiency in dementia care.

It is also important to note that CNAs, unlike registered nurses (RNs), advanced practice providers (APPs, such as nurse practitioners and physician assistants), and doctors, have minimal training in medical evaluation and triage. And higher level licensed clinical practitioners (who do have this training) are often not required to be present in the building at all times. This means that, at any given moment, prompt medical evaluation may not be available onsite. Not surprisingly, research has shown that ER visits are more common among assisted living (and memory care) residents.

Memory care units are not regulated to be health care facilities, nor are they regulated to have rigorous staff-to-resident ratios. And yet some facilities go above and beyond regulations to ensure the highest quality staffing possible. Find out which ones these are!

What is access to medical care like in the ALF/memory care unit?

One important and unfortunate consequence of the structure of memory units in America is that, all too often, residents lack timely access to high-quality medical care, especially primary care. Residents are often dependent on the facility for transportation to and from appointments, and communication and care coordination can be quite challenging. Ask questions about how facility staff communicate with patients' primary care providers, and, for example, whether or not such providers come onsite and visit their patients in their apartments. If your loved one has mental health needs associated with dementia, this is a particular area to ask about. Some facilities have access to psychiatrists who come onsite to care for patients; this is ideal!

How does the design of the memory care space affect daily activities and nursing supervision?

This question is far more important than it might seem. Answering it requires both keen observation during visits to memory units and conversation with an ALF's nursing leadership. There are many different layouts to memory communities. Some encourage large gatherings of residents in a single space; others have multiple spaces for small gatherings or activities. In some spaces, it is easy to see how limited staff preoccupied with one or two residents might not be able to provide simultaneous support for others; in others, the design is purposefully conducive to such supervision.

Imagine your loved one in such spaces. Consider what might be typical flow to their day, with and without other residents, and to what degree that might align well (or poorly) with their routines and preferences