Planning for All the Stages of Alzheimer’s Disease and Memory Care: Multiple-Level Assisted Living

Stages of Dementia

Making the decision to place a loved one in a 24-hour care home is difficult for anyone. Making the best decision involves a number of factors and is best done by personally touring options near to your home. Most of us have seen the checklists for touring assisted living, they are provided by agencies like AARP (,  or you can find several checklists and a financial planning calculator at the County of San Diego Aging and Independence Services website “Choose Well” ( The checklist is an important tool to compare facilities as you tour them. The list looks at everything from building maintenance to Resident care and cleanliness, to staffing ratios and activities offered, to meal prep and presentation.

There is one area that the elder care facility checklists do not specifically address: memory care. If your loved one has a cognitive impairment, dementia, or Alzheimer’s Disease, you need to seek out an all-inclusive, multi-level community that can provide care at every stage of memory loss. Because the general checklists do not address this, you must look down the road. You need to research which facilities can support the changing needs of a person facing progressive memory loss.

Selecting a care facility is all about creating a network of support for your loved one.  Ask what will happen when your loved one, who currently has Mild Cognitive Impairment (MCI), progresses through the stages of memory loss. Will they have to move out to a higher-level care community? Wouldn’t it be better to ensure continuity of care in a familiar place? Most of us would strongly prefer to avoid the stress (on both of you!) of having to move them to another community each time their memory loss progresses.

When memory loss comes into the equation, here are some important questions to ask during your care facility tour:  

  1. Can the facility you found step-up and surround your loved one with staff trained in the middle and advanced stages of memory loss? Do they have staff trained in the late stages of dementia? What partnerships do they have with traveling physicians, nurses, psychiatrists and hospice or palliative care organizations?

Any memory care facility worth their salt has care and safety training, ongoing video trainings, monthly in-services and their new hires have several days of shadowing a more advanced Caregiver before working the floor. They also have access to a travelling team of medical providers. This team can be contracted when it is difficult to take a resident out to the doctor’s office. They also will have a relationship with several palliative (pain and symptom management) and hospice (end-of-life) agencies.

Red Flag: Do they state they can only take people with Mild Cognitive Impairment? That is a warning sign that they don’t specialize in memory care and may not have the required building safety features. In that situation, when your loved one starts to exhibit a change in behavior, including things like wandering, they will ask you to move.

  • Ask about how isolated their advanced stage memory care residents are from the rest of their population. People with memory loss need stimulation to stay engaged in everyday life. Do they include everyone in activities and holiday parties? Do their highest care residents interact with volunteers or visiting kids? Do they know how to adjust activities based on abilities and safe use of supplies?

It is important that they understand isolation and staying in bed is the quickest way for someone with memory loss to lose their remaining skills and abilities.  They should understand the importance of daily exercise, music, daily time in nature and pet therapy. They should understand how to set up an activity for their residents, with all the supplies in order and clear step-by-step directions. Additionally, the activities should be dignified. (e.g., It is okay to have a crayon or colored pencil coloring activity, but the staff should call the activity “Art” and the coloring pages should be adult themed and large print. If they are singing as a group, the song should be one they learned as an adult, not “I’m A Little Teapot”, unless of course, young volunteers are visiting with them).

Early Red Flag: If their building is multiple-story and they have a special floor or neighborhood for memory care, they are likely too isolated from the community and from nature/natural light.

  • Ask how they respond to memory loss symptoms like confusion, agitation, repeating of a story, Sundowner’s or middle of the night puttering and rummaging. What safety and security measures have they included in the built environment? What is the staffing ratio at night?

With a memory care or Alzheimer’s disease diagnosis, it is important to recognize that the disease is a progressive one and you can expect your loved one to have variable days—some days that they are really lucid and some days with greater levels of confusion, where they need an extra hand. You can also expect a time when your loved one will be exit seeking—they believe they have to be somewhere or meet someone, and it becomes urgent to find an exit. Safety features such as pass-code gates, and double gated egresses, or off-set doors (less noticeable to exit seekers) can help ensure their safety.

Early Red Flag: They have mini-apartments that people can stay in all day, or they don’t have a standard practice of staff inviting residents out to join in on meals and activities.

  • What is the cost difference when a resident’s care needs increase? When you tour, find out, do they have a “concierge menu” of additional services? What is included in the base rate? Do they have an all-inclusive locked rate?

When your loved one needs help with making their bed, medication reminders, or support with toileting, do each of these things have an added charge to the base rental rate? If the answer is yes, that answer is telling! A couple of things—it means they are a bigger facility with many more people to attend to and staffing will be allotted to check in on people who paid the up charge.

Early Red Flag: Not all staff is trained in memory care, including the day to day changing moods and abilities of people with mid and late stage memory loss.

  • What is their facility’s communication process? How often do they keep in contact with you? Who is the person to call if you have questions? Under what circumstances would they contact you?

Having clarity regarding your loved one’s care and any changes in their condition is crucial. Do they have a clear path for communicating with their Director of Care and the Lead Medication Technician working each shift? Are they arranged into smaller homes or cottages with one main Caregiver that you and your loved one can really get to know and trust? Communication and trust become increasingly important as your loved one becomes more vulnerable and may need more support with activities of daily living like showering and dressing.

Early Red Flag: Caregiving staff stay at a nurse’s station. You want to see staff out on the floor, joining in activities and being present with the residents, encouraging them to participate, calling them by their name (or their nickname) and noticing their needs.

Hopefully the basic assisted living checklist, along with the questions regarding memory care, will help you in selecting a wonderful community. When you tour, listen to your gut and try to find a memory care specialist. One example is Sunshine Care Assisted Living Homes in Poway, North San Diego County, California. They are an award-winning community of assisted living homes specializing in memory care. Their dedicated care teams understand all the variables that come along with memory loss. Sunshine Care’s staff walks a fine balance between autonomy and support, in safe and secure environments. They are also unique with four levels of care. Level 1 includes six-bedroom homes with a live-in caregiver (beginning memory loss). Level 2 is six-bedroom homes with 24-hour awake staff for those with beginning to middle stage memory loss that are active at night (this is not uncommon).  Levels 3 and 4 are specifically designed to serve middle through advance stage memory loss. Their model provides peace of mind, because they can appropriately address any change of condition across the spectrum of memory care. To learn more about Sunshine Care and their multi-level memory care, visit or call their toll-free number at 1-800-811-9595.


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