Assisted living is one of the fastest growing areas of health care, as many who are in need of long-term care are seeking out the aesthetically pleasing, homelike environment of assisted living rather than the institutional skilled nursing environment.

The problem

There are a number of people who are living in assisted living facilities (ALFs) who have some degree of dementia—and too often, the difficult problem is that these residents are not identified or treated appropriately.

According to the 2016 Alzheimer’s Facts & Figures [PDF] report by the Alzheimer’s Association, 42% of residents in assisted living have some form of dementia or cognitive impairment, and that number is increasing every day.

Yet only 58% of those facilities provide a memory care program.

The solutions

These facts and our own experience and observations indicate that environments are often ill-prepared to care for this population. We believe that the root of the care management problem is in the resident admission and ongoing assessment process.

In many ALFs, the resident assessment performed by the facility is very lean and is often more like a questionnaire of needs than a professional assessment of needs. A physician assessment is usually performed prior to admission, but often this does not adequately identify the cognitive status and the specific associated functional limitations or abilities of the client. Many people move to an ALF in Allen level 4, and we know that in Allen level 4, persons will have IADL and then ADL needs. However, we also know that these individuals are not good self-reporters of needs.

In our experience, a facility may have half of its residents performing in Allen level 4, and this is the level in which we have witnessed the greatest discrepancy in what is delivered versus what is actually needed. We know the problem is associated with the often relatively intact verbal skills fooling the assessor. It will then take time for the facility to realize that Mrs. Smith is having some problems, and by then the problems may have led to a serious issue such as a fall or depression leading to hospitalization.

The key for success is rooted in enhancing the facility assessment process. This should be done in two ways:
  1. Improved resident assessment performed by the facility. The facility must identify a team member within the environment who can perform a comprehensive evaluation of needs. The evaluation is usually performed by the Director of Nursing or other lead nurse. The evaluation should include a cognitive assessment such as the FAST, GDS, MMSE, and/or SLUMS. In addition, the assessment should look at other areas that impact function such as physical limitations and sensory loss. The assessor will then make a determination of the level of assist the resident may require. This will help eliminate the trial-and-error getting-to-know-you process that typically ensues after admission.
  2. A professional therapy assessment. Many ALFs use home health as the only source of therapy involvement. Most often, the delivery of service involves coming in AFTER the resident has had a medical issue and/or hospitalization. This doesn't solve our need for a proactive therapy assessment to help identify the care needs and necessary approaches for a complex client. We recommend an ALF partner with a therapy organization who can bill Medicare Part B and is trained in the Allen theory. We suggest the therapy team be on site five days per week and truly become a part of the ALF team. When a resident is admitted who has an Alzheimer's or related dementia diagnosis, the therapist can perform an evaluation, including the Allen cognitive assessment, identify the person's best ability to function, and create a plan to maximize and maintain the person's function and safety.

Another essential element for success is dementia care training for all facility staff. Over 30 states in the US now require some amount of specialized dementia training for facility staff of an ALF that markets caring for persons with dementia. We believe it is absolutely essential that staff are prepared with a quality dementia training program to help them understand the complexities of the disease and approaches that work.



In our opinion, many assisted living facilities do not know the complexity of the clients that they're serving. Many are oblivious to the pervasiveness of dementia and the relationship of dementia to poor outcomes and high liability. This is a golden environment for therapists to be a part of as we infuse a high degree of sophisticated medical and dementia assessment/care knowledge that will help the residents and the facility succeed. We believe that ALFs can be a wonderful alternative to skilled nursing facilities or to remaining at home. However, these environments must begin to provide the expertise needed to serve persons with dementia.