Designing memory care

[Editor's note: This is part one of a two part article. Read part 2 here: Trading spaces]

About 5.2 million seniors received a diagnosis of Alzheimer’s disease in 2014, and most will be seeking some level of memory care services over the next five to 10 years, according to the Alzheimer’s Association. And that number only includes Alzheimer’s, just one type of cognitive impairment. Got your attention?

But determining how to provide those memory care services and environments—and align them well within business models—has many long-term care (LTC) organizations going back to the drawing board on how they think about memory care service delivery. Better think fast—the market inventory of memory care units has surged by more than three percent in the past 18 months, the fastest-growing market segment, according to a September 2014 housing market report from National Real Estate Investor.

Plenty of organizations also are revisiting their services and spaces traditionally allotted to assisted living and are re-forming them under the memory care banner. “We are seeing an expansion of dementia providers, people taking some of their assisted living beds and turning wings or different floors into dementia care. There’s a huge need,” Maribeth Bersani, senior vice president of public policy for the Assisted Living Federation of America, told Long-Term Living in December. But what do quality memory care services actually entail, and what real changes need to be made to compete in the growing market segment?


Building a successful portfolio of dedicated memory care services obviously should begin with high-quality nurses who are professionally trained in the niche of memory care, including a director of nursing (DON) who deeply comprehends that many memory care residents will spend years living in a unique space, somewhere between assisted living and skilled nursing. Much of the nurse training will be in gaining clinical awareness of the special “translation” needs of cognitively impaired residents, and how to change how the nursing staff and clinical programs interact with them.

But launching a memory care center can affect the clinical workflow schedules greatly. For example, organizations that operate dedicated memory care centers often find that adjustments need to be made to the traditional nursing shifts, to avoid a staff shift change during the crucial late afternoon period when many residents with dementia will experience “sundowning,” a daily phase of heightened agitation and confusion.

Memory care services also raise business discussions about another service line: end-of-life care. Many memory care centers choose to offer care and support only until the need for the skilled nursing level is reached, and then residents are transferred to skilled nursing units. Other organizations are now providing end-of-life care as part of the memory care service line. The business decision is a weighty one, based partly on reimbursement, especially in the for-profit sector.


Memory care services, often born from the assisted living realm, also involve dozens of other staffers beyond the DONs and charge nurses. Nursing assistants, direct-care workers and other support staff provide constant assistance with the activities of daily living, including bathing, eating, dressing and toileting. And those skills don’t necessarily transfer equally from skilled nursing environments to memory care environments. The support staff’s level of training in working with cognitively impaired residents can make or break a memory care program’s success.

Even a simple activity, such as eating, involves special hurdles for residents with cognitive challenges. Dementia often causes unique problems in translating what the eye sees to what the brain understands, leaving a resident unable to “see” the difference between white bread and a white dining plate, notes Alice Cronin-Golomb, director of the Vision & Cognition Laboratory at Boston University, whose 2004 research connected red dinnerware with increased eating habits in people with dementia. Because of this unique need, red plates, cups and utensils have become common choices in memory care centers—being both high-contrast and in an appetite-stimulating color.


One of the biggest mistakes a new memory care center building project can make is not tailoring the interior design to the specific resident population. The “eye tricks” experienced by residents with dementia extend beyond the dining room to other realms, right down to a resident’s own bathroom. Using different colors to provide clear demarcation between the floor and the wall, or to outline the area surrounding the toilet, can help residents discern the difference between surfaces.

Likewise, color is crucial in wayfinding and “space identity” for those with memory impairments, creating a crucial need to meld interior design with the clinical care missions. Bold, complex patterns can agitate or confuse those with dementia, especially in flooring. “When rugs, couches or wallpaper have big designs on them, the residents can think they’re stains and will keep trying to clean them or pick them up,” explains Joshua Freitas, CAEd, CADDCT, CDP, founder of Memory Care Innovations, West Bridgewater, Mass. “And the pictures on the wall need to be real, not abstract. A horse needs to look like a horse.”

Those crisp white doors and matching door trims may be attractive from a design standpoint, but aren’t the best choice for a memory care center, Freitas adds. “We have to look at the living environment through the residents’ perspective. Residents can learn that they live on the purple hall or that their own room has a green door. It’s not about making it look nice. It’s about what’s best for the residents and their abilities.”


Long gone are the days when dementia care was limited to keeping residents calm and safe. The person-centered care movement has brought a welcome emphasis on high-quality programming that reaches far beyond activities that merely keep residents “busy” or “distracted.” Now, memory centers are expected to reach for a much higher bar, offering activities that engage residents’ intellectual, emotional and thought-process aspects and preferably all day long, not just during “activity hour.”

Person first

CCAL-Advanced Person-Centered Living, a non-profit national consumer advocacy and education organization, has developed core values that should be part of any memory care initiative:

  1. Every person has his or her own meaning of life, authenticity (personality, spirit and character), history, interests and personal preferences and needs to continue to experience life at all stages of dementia. The person is not the dementia illness. Rather, the condition is only one aspect of a person’s current status.
  2. Focus on the strengths of the person living with dementia rather than on what abilities and capabilities have been diminished or lost.
  3. “Enter the world” of the person living with dementia to best understand, communicate with and interpret the meaning of his or her behavioral expressions from their perspective.


This marked culture shift has inspired some memory care centers to weave activities programming into the residents’ entire day, including activities that exercise their skills in problem-solving, item-sorting and communication with others.

Successful programming needs to reach across all residents while being adjusted for the levels of decline, Freitas says. “It’s best to keep the residents all doing the same activities, but with different levels of support. Early-level residents might be able to mix cookie dough and talk about ingredients and use the cookie cutters, while residents in later stages might just hold onto the dough and smell it. It’s the same activity, but using very different levels of support and connection.”

These trends also have created a vibrant new landscape for the role of activity directors, a role that has exploded both in importance and in skills training over the past two years.


LTC organizations can shift and rename their bed spaces any way they wish, but if they don’t also make progressive and meaningful changes to their memory care services and programming, the savvy consumer base will notice. “Assisted living is booming, and everyone is converting sections of their buildings into memory care,” Freitas says. “But how many of them are involving their residents in all aspects of their care and letting residents help choose what goes on there?” Just because residents have cognitive impairments doesn’t mean they have no say; it just may be a different kind of say, he explains.

“Use questionnaires to tap into the interests of the residents when they first move in. Question the residents and their families. That can help dictate what the ongoing culture of activities will be,” he suggests. “If they loved knitting in the past, all we have to do is provide the yarn and knitting needle. But they’ll lose that known skill if we don’t give them a way to continue it.”

Related article: Trading spaces

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