They are individual s who need highly specialized care and they’re populating assisted living communities at a rapid rate—and that influx is only getting faster. Currently, 5.3 million seniors have Alzheimer’s disease—the largest number in the nation’s history. And by 2050, that number will jump to 14 million, creating an even greater demand for Alzheimer’s care, largely in assisted living settings.

While capacity will be an issue, the good news is that providers are better prepared and positioned than ever to provide that care. Over the past few decades, a major shift has taken place in Alzheimer’s and dementia care, one that rejects heavy medication and recognizes that people with memory loss still can have a high quality of life by living in their “unique present.” The last few years have not seen radical new approaches to care, but proactive providers are preparing for more memory care residents—not only by incorporating brain fitness programs into their general wellness strategies, but also by fine-tuning memory care programs to enhance quality of life through all stages of dementia.

Here’s a look at the latest strategies at work for providers, and the trends that will continue to influence operations as the Alzheimer’s population grows. Among the biggest trends in Alzheimer’s care is a matter of timing. More seniors are requiring care in the earlier stages of the disease, some even as a preventive strategy before any diagnosis is made, says Stephen Winner, co-founder and chief of culture for San Juan Capistrano, California-based Silverado Senior Living. The company operates 20 communities that specialize in memory care in Arizona, California, Texas, and Utah.

Driving the trend toward earlier care are scientific developments, including improved MRI and PET scans, cerebrospinal fluid tests, and blood tests that detect Alzheimer’s and Mild Cognitive Impairment (MCI), a condition that sometimes precedes Alzheimer’s disease.

Earlier, Evolving Needs

Looking forward, a new, simplified assessment tool also may soon contribute to earlier Alzheimer’s diagnoses and care. Researchers at the Emory University School of Medicine in Atlanta are working on a simple pen-and-pencil test that takes only three minutes (as opposed to current 40- to 60-minute brain health exams which due to their length are unlikely to become routine at primary care physician visits). This test would not determine a definitive diagnosis but would indicate a need for further assessment.

“One of the most amazing things at the dementia conferences I go to now is that so many of the participants have MCI or an early diagnosis of dementia,” Winner says. “In the future, it’s not going to be the family members, but the persons with dementia dictating what their care will be. I think that’s going to have a big impact on our industry.”

In the past, a dementia diagnosis often was devastating because the individual would have lost so much mental capacity already, Winner adds. Now growing evidence suggests that onset can be delayed with new medications and a number of lifestyle factors, including exercise, healthy diet, lowering stress, social interaction, and staying cognitively active. Early diagnosis, therefore, can mean a much higher quality of life for a longer period of time, and assisted living should be preparing itself to help people achieve that, Winner says.
“The numbers are so huge that there is going to be a need for all kinds of models, including some that don’t already exist.”

Cognitive Fitness

A 400-person crowd attended a “Cross-Train Your Brain” presentation at a Brookdale Senior Living community in Jacksonville, Florida, this spring. But the large volume of participants came as no surprise to Brookdale executives; this has been the response to several similar events throughout the country, says Kevin W. O’Neil, medical director of the Brentwood, Tennessee-based company’s Optimum Life program. The presentations, which feature leading clinicians and researchers, educate seniors about how to improve their cognitive health and reduce the risk of developing Alzheimer’s or other types of dementia through lifestyle modifications, including better nutrition, exercise, and brain games.

A rapidly rising number of seniors, including many not diagnosed with dementia are keenly interested in methods to prevent or delay memory impairment, O’Neil says, and communities that offer cognitive health programs already are experiencing a competitive advantage in their markets.

One strategy at work in more than 700 senior living communities nationwide is the use of computerized brain fitness games. This high-growth technology sector did not exist just five years ago, but in 2008 it generated $265 million in revenues, according to Sharp- Brains, a San Francisco-based company that tracks the cognitive fitness industry. Revenues are predicted to be $1 billion to $5 billion by 2015.

For many seniors, the brain games are fun and encourage cognitive exercise in the same way that a group aerobics class stimulates some to exercise. For this reason, Brookdale Senior Living has introduced software by Dakim at several of its communities, and O’Neil expects them to become increasingly popular with tech-savvy baby boomers, many more whom will soon start moving into senior living. O’Neil says the key factor for choosing brain fitness programs is the same as physical exercise programs—that seniors find them simple and enjoyable.

The Dakim system, for example, uses touch screens—an important feature for seniors who find it difficult to manipulate a mouse or use a computer keyboard. The average resident at a Brookdale community is 86 years old and did not use computers during his or her professional life, so the touch screens are particularly convenient. And because social interaction also is a strategy for fending off dementia, O’Neil suggests making the brain fitness games part of a comprehensive care program, and warns against any kind of activity that could isolate residents for long periods of time.

For example, people tend to have more fun exercising in groups or with a partner, O’Neil explains. “The social engagement can be more powerful than August 2009 | www.alfa.org New Reality for Residents with Alzheimer’s the social activity itself.”

Silverado also is participating in a pilot program using Dakim games at one residence and will roll it out to more communities if playing yields measurable outcomes, Winner says. As with any other program, make sure the brain games you select fit residents’ level of cognitive ability. “You don’t want to pick a game that is so difficult that three to four residents can answer the questions, but 10 can’t,” he says.

To help providers navigate the growing number of brain fitness products, SharpBrains has published “The Sharp- Brains Guide to Brain Fitness.” This first consumer guide to brain fitness products includes interviews with 18 scientists about brain health and reviews of 21 products.

However, cognitive activities do not have to be high-tech to yield brain benefits, O’Neil notes. “All our communities have cognitive programs that are low-tech, too. In one Cleveland community, residents play Concentration; in another community, they play a form of Trivial Pursuit. These are things we were doing long before computer games came along.”

Everyday Adaptations

No matter what steps people take to delay dementia, the greatest risk factor continues to be age and Americans are living longer than ever. Therefore, at least in the foreseeable future, seniors will continue to develop and be diagnosed with middle- and late-stage Alzheimer’s disease, and assisted living providers will continue to hone their care strategies to best serve their needs. An important part of that ongoing process is fine-tuning and adding to evidence-based programs senior living companies already have in place.

For example, for many years, McLean, Virginia-based Sunrise Senior Living has focused on “life skills” as a way to bring meaning and purpose to residents in its Reminiscence (memory care) neighborhoods, says Rita Altman, national director of memory care services. But the company recently created the new position of life enrichment manager on each community’s memory care services team devoted to translating life skills into life-enriching activities customized for each resident.

“That person will be key to ensuring that a resident is still able to do what they enjoyed in the past or helping to adapt whatever they did in the past to what they can still do now,” Altman says. “Life skills are built into many dementia care programs, but often they can get pushed aside unintentionally due to the tasks of the day. Having a life enrichment manager ensures that they happen.”

For example, if a resident’s profile shows he was a business owner who enjoyed greeting customers, the life enrichment manager might adapt that activity by finding a place for him to sit where he can see others coming and going, Altman says.

In another example, Brookdale Senior Living has introduced a specialized dining program to meet the needs of its 5,200 Clare Bridge residents, those with Alzheimer’s and dementia. Through various strategies, ranging from special seating arrangements to food preparation and presentation approaches, Brookdale has found success in making an everyday experience a more enriching and enjoyable experience for its Clare Bridge residents. A winner of an ALFA’s Best of the Best Award this year, the dining program helps residents surmount the challenges of eating and “gets beautiful meals to their mouths,” says Juliet Holt Klinger, Brookdale’s director of dementia care programs.

“When you look at the service day in any typical organized living situation, dining is a huge component—about six hours,” she adds. “We felt it should be specialized, too.”
Residents eat the same high-quality meals served in Brookdale’s assisted living communities, but a team of gerontology and culinary experts has developed menus that eliminate tasks that could be difficult for someone with Alzheimer’s, such as requiring different steps (e.g., eating with a fork and hand in the same meal). In addition, caregivers use handunder- hand prompting techniques, which allow residents to continue using utensils and maintain control over their eating process longer.

Successes have been inspiring, Holt Klinger says. “We find that after doing these things, people grab glasses again,” she explains. “There are countless stories of people being fed and then we’re able to get them to feed themselves with these techniques. It’s made a big difference.”

Anya Martin is a contributing writer to Assisted Living Executive. Reach her at  amartin@alfa.org.

Who’s Who

Contact information for members in this article.

› Rita Altman, Rita.Altman@sunriseseniorliving.com
› Juliet Holt Klinger, jholt@brookdaleliving.com
› Kevin W. O’Neil, KOneil@brookdaleliving.com
› Eric Portnoff, Lynnwood.ed@sunriseseniorliving.com
› Nader Shabahangi, Nader@agesong.com
› Stephen Winner, sfwinner@silveradosenior.com  

The Holistic Path to Memory Care

Nader Shabahangi, founder and CEO of AgeSong Senior Communities, operator of three assisted living and dementia care communities in the San Francisco area, prefers the term “forgetfulness” over memory loss or dementia and believes passionately in a holistic approach toward physical, mental, and spiritual health. Shabahangi’s communities seek to empower residents’ bodies and souls through an array of innovative strategies, from community tea shops to film festivals, feng shui décor to organic gardens.

Not surprisingly, Shabahangi sees Eastern philosophy as a provocative lens for Alzheimer’s care. Age Song care strategies seek to “re-imagine” living with Alzheimer’s to create a uniquely freeing experience.

“In the west, ‘dementia’ means no mind, or away from mind; in the east, it is a state of enlightenment,” he explains. “Now the person afflicted with forgetfulness is our teacher. That’s a fundamental shift away from the custodial care concept—‘oh, poor thing, we have to take care of you.’”

Like many providers, Age Song takes many of the communication strategies from Naomi Feil’s validation therapy techniques, first published in 1990, which encourage caregivers to use empathy to enter the world of a person with memory loss. From that foundation, Age Song has developed a training program that directly addresses the quandary—how do you get people used to living in their own me-centered universe of past-present-future to embrace the world of another’s just-present?

“It’s one of the most difficult things in the world to have an open heart and stay with another person’s reality rather than your own,” Shabahangi explains. He equates the experience to a first-time mother learning what her baby wants through the infant’s nonverbal cues or the nervous excitement of exploring a foreign country where one does not speak the language. Instead of being a stressful process, Shabahangi emphasizes curiosity and acceptance. “What can I learn from the other?” he poses.

About a year ago, McLean, Virginia-based Sunrise Senior Living developed a new training program for memory caregivers called Reminiscence: A Journey of Discovery. The program, just one aspect of the company’s comprehensive memory care strategy, focuses on using empathy to “validate residents’ feelings and offer them opportunities for finding meaning and purpose through life enrichment programs,” says Rita Altman, the company’s national director of memory care services.

“Nobody knows what it’s like to experience memory loss, but we sure can share the same emotions,” Altman says. “We can take deep, centering breaths, get rid of our internal issues, and go into the world of the resident.”

After completing the training program, Eric Portnoff, executive director of a Sunrise community in Lynnwood, Washington, decided to try the validation techniques he’d learned— which included listening, observing, and matching a resident’s tone, expressions, and emotions. He says he sat down with a woman with advanced dementia who spoke only in “word salad.” Words came out but not strung into sentences that made sense. He spent 30 minutes mirroring her emotions, listening intently when her tone was serious and she started to cry, and laughing with her when she shifted to a happier mood.

“Then she turns her head to me and looks me right in the eye, and says ‘thank you for listening to me,’ just clear as a bell,” Portnoff says. “It was like clouds parting.”

At the end of a second cycle, the woman suddenly exclaimed, “You’re beautiful” to Portnoff. He responded, “‘No, you’re beautiful.’ It went back and forth, and again there was a sense she was really there and we were connected,” he says.

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