The following was originally printed as a guest editorial in the American Journal of Alzheimer’s Disease and Other Dementias
Volume 17, Number 4, July/August 2002. You can view the article in its original context here.

An integrated memory-loss/assisted living program, the first to be licensed in the state of Rhode Island, has been operating successfully for over a year. The model program at Victoria Court Center for Geriatrics in Cranston, Rhode Island, was designed to integrate dementia patients into the daily activities enjoyed by residents with no cognitive impairment. The model, which also includes special care planning, staff training, admission/discharge criteria, and plans for the adaptation of the physical environment for residents with dementia, can be replicated at other facilities using the following program guidelines and with the advice of their licensing agency.

We often hear about locked units and wards. But the real questions surround the concept of separation versus integration. Are there advantages to separating those with dementia and Alzheimer’s disease from those who live independently in assisted living facilities? Or is it more advantageous to allow Alzheimer’s and dementia residents to live harmoniously with independent residents?
Today, the new buzzword in the field of Alzheimer’s care is integration, which is defined as a method of mixing populations within a residential setting. Combining a group of Alzheimer’s and dementia residents with those who are independent can lead to a higher quality of life for both groups. But, you’re probably thinking, how can that work? Why would independent individuals want to be around residents with dementia? The answer is simple. Many independent residents, even those who are depressed, have a need to fill a void within themselves or to be helpful. Reaching out with a helping hand, in many cases, makes them feel better about themselves. For many residents, it “feels good” to be a humanitarian.

Visualize a utopian-like commune of orderly elders conducting their daily activities around a structure of social recreation and rehabilitation.1 Independent residents can be seen guiding and redirecting a wandering Alzheimer’s resident. Think about a lonely and depressed independent resident spending time with a resident who has mild Alzheimer’s disease or first-stage dementia.2 The once withdrawn and lonely resident now has a friend to help.3

It is not as easy as it sounds, of course. The difficult task is putting together a well-planned, integrated program that ensures safety for all of the residents, as well as the staff. Drafting the program is the first step, which should start with a mission statement.

Mission Statement

The introductory portion of the mission statement needs to address the unique and specific environmental needs of residents with Alzheimer’s disease, dementia, and other related memory loss, to allow them to function at their highest possible level. The program should address staffing needs, provide an adaptable environment for fluctuating behaviors, and ensure continuity of caregiver assignments. Appropriate physical space and specially tailored therapeutic activities are additional considerations. The main focus of the program needs to be on the residents’ capabilities, not on their limitations. Quality care, which includes quality of-life issues, needs to be the top priority.

Admission Criteria

An interdisciplinary team needs to do a preliminary assessment of each prospective dementia resident to determine suitability for the integrated program. This assessment should include the person’s medical, psychosocial, and nutritional needs. In addition, at this stage, the team should:

  1. Encourage early-onset individuals and their caregivers to record symptoms and other observations to share with health care professionals;
  2. Help families discuss changes they see in the person and how they feel about them; and
  3. Refer the resident and/or family to support groups to share feelings and develop supportive relationships.

Final criteria for admission to the integrated program should include:

  1. An assessment that the prospective resident has Alzheimer’s disease, dementia, or another disease process that affects memory and the ability to live independently;
  2. A decision that the resident will benefit from being in a safe, secure, and low-stress environment that includes independently functioning residents; and
  3. Assessment results that predict that the resident will benefit from a structured program that focuses on capabilities and enjoyment, rather than limitations.

Care Planning

Once the interdisciplinary team has determined a resident’s appropriateness for the program, the next step is to create an individualized care service plan, based on evaluations of the person’s cognitive abilities and functional status. Care plans need to include compensatory services (assisting residents to compensate for activities they can no longer perform independently) and restorative services (aimed at restoring function). It is important to assess the severity of symptoms associated with Alzheimer’s disease and dementia, such as anxiety, agitation, aggression, repetitiveness, wandering, shouting, and sleeplessness.

Quarterly reviews of the care plan should include input from the interdisciplinary team and other staff members. Each review should evaluate progress, identify any new concerns, and determine whether goals should be modified. Changes in condition need to be monitored and addressed. Families should be invited to participate in the care-planning process and be notified of needs and changes as they develop.

Discharge Criteria

Adhering to the following list of discharge criteria is essential for achieving success in the integrated program. Residents will no longer be considered appropriate for the integrated program and be discharged when:

  1. It is determined that the program can no longer meet their needs;
  2. Their behavior becomes such that it disrupts the lives of other residents, e.g., yelling, threatening, or being physically or verbally abusive;
  3. Their behavior prevents the staff from meeting the resident’s basic needs, e.g., bathing and dressing;
  4. They can no longer feed themselves;
  5. The resident’s behavior threatens his or her own safety or the safety of other residents, visitors, or staff members of the program (includes emergency discharge to an appropriate setting, including a psychiatric hospital);
  6. A resident or a legal representative fails to accept psychiatric intervention (if this service becomes necessary, it may be grounds for immediate discharge);
  7. A resident or a legal representative fails to provide medical information (may be grounds for immediate discharge);
  8. A resident’s decline in mobility requires use of a Hoyer lift (not allowed in assisted living in some states) for transfer;
  9. A resident’s behavior becomes abusive to the program setting, e.g., the resident damages property;
  10. A resident fails to comply with facility rules and regulations;
  11. A resident or legal representative fails to pay for services and rent as agreed upon; or
  12. A resident begins to need medical/nursing care (planning will be initiated).

Staff Training

The Director of Nursing should oversee the program. The direct care staff-to-resident ratio should be 1 to 8, days and evenings. Ongoing training should be provided to all staff, using materials from the Alzheimer’s Association and other outside resources as necessary. Staff members should receive a minimum of 12 hours of training per year and be kept abreast of current techniques in caring for the resident with memory loss. Sensitivity training should be a component. Attendance at workshops will improve staff responses to the noise and movement within the residence and to the needs and behaviors of the residents with dementia.

Physical Environment

The physical environment should be adapted to support cognitively impaired residents and include space for safe, independent wandering. A security system for wanderers should be installed, so that dementia residents can wear bracelets that will alert the security system if they begin to wander outside the secure area. All outside doors need to be alarmed with the security system. The front door should also be alarmed for anyone entering and leaving after the receptionist leaves for the day. All doors leading to the outside and to the stairs need to be equipped with magnetic door locks and a push-button code access panel to open the doors (by regulation of the Fire Code and with the approval of the state’s fire marshal). Benches and seats should be placed near elevators and in designated areas for rest. Color tones need to be subdued and the environment needs to be quiet and tranquil. All walking areas have to be sufficiently lighted. Sensory cues need to be provided for orientation. An outside courtyard, enclosed with locked gates, is important as well. All trees and shrubs need to be carefully planned to ensure safety to the residents. Plant material should not have thorns and berries.

Familiar staff members, common areas for safe wandering and freedom of movement, appropriately secured windows, and a simplified but structured activity program of social recreation and rehabilitation1 are some features that will create a positive environment for the resident with dementia.

Resident Activities

The activities program should empower, support, and maintain residents under the supervision of a certified activities director, with a daily activity schedule posted for the residents. There should be opportunities for small group and one-to-one interactions. Ratio of staff to residents should be no greater than 1 to 8 during each activity. Time for rest or naps also needs to be included. A structured plan for incidents of inappropriate or challenging behaviors during integrated activities is needed.

Activities should focus on sustaining current functions, managing behavioral symptoms that accompany dementia, and preventing premature functional decline. The focus should be on gross motor skills and sensory ability enhancement, social activities in both indoor and outdoor settings, and validation therapy. Residents need to experience laughter and fun, and recover treasured lost memories. Activities will help stimulate memories, and provide pleasant experiences and a means of creative self-expression. The integrated activities program needs to be in a distraction-free environment, with emotional support and environmental cues. The activities also need to combine fitness and the arts to strengthen the links between healthy bodies, minds, and emotions. The goal is to assist in developing interdisciplinary programming that includes residents with memory loss. Assisting residents with memory loss in an integrated program setting will enhance their feelings of control and help them maintain their safety and dignity.

References

  1. Zeltzer BB: Participants sought for rehabilitation study. The Brown University GeroPsych Report. February 1999; 3(2): 2-3.
  2. Zeltzer BB: Pairing a dementia resident with a roommate may aid depression. The Brown University GeroPsych Report. March 2000; 4(3):1, 7-8.
  3. Zeltzer BB: Roommate-pairing: A nonpharmacologic therapy for treating depression in early to mid stages of Alzheimer’s disease and dementia. American Journal of Alzheimer’s Disease and Other Dementias. March/April 2001; 16(2): 71-72.