When Is It Time for a Nursing Home? Alzheimer's Dementia Care


hello Matthew Bell with Alzheimer's

proof calm and today I want to talk to a

little bit about that point in time

where it becomes necessary to make the

decision to put your loved one into a

nursing home

specifically I want to think about the

question of when is it time to put your

loved one into a nursing now this is a

huge and traumatic issue I can tell you

this is gonna be heavy going I'm gonna

go through a lot of stuff I was

surprised in preparing for this video

the number of times I actually teared up

reminiscing about my dad and so it's

it's tough this is difficult material

it's also complicated material it really

is complicated and the answer is gonna

be different for everybody and you

should understand this right from the

beginning first of all we know

Alzheimer's has multiple stages many

times its enumerated as 3 there's also I

have a video up with the link in the

description put a screen shot up maybe

where I talk about the seven stages view

versus the three stages view but we

don't have to deal with any of those

niceties here we can simply say

intuitively Alzheimer's is early middle

and late stage so everybody's experience

is going to be a little bit different

everybody's actual symptoms of

Alzheimer's are gonna be a little bit

different their care environment

everything is going to be unique to

their circumstance and so there's no

one-size-fits-all answer that's for sure

somebody could theoretically progress

through the entirety of Alzheimer's in

other words do a full progression from

early middle to late stage and die as my

dad did from the Alzheimer's directly

and they could be in their home the

entire time that is possible on the

other hand a person could perhaps have

to enter into a care environment very

early maybe even with mild cognitive

impairment or in an early stage of

Alzheimer's disease they may require

nursing home care and one reason for

that might be that they have some other

condition or conditions that reduces

their ability to care for themselves

apart from the Alzheimer's so every

family every person their experience

here is going to be entirely different

the most that I can hope to do is kind

of run through a series of

considerations that I hope might assist

you in trying to work through these

issues for yourself and for your family

but because of the complexity and

because of time limitations in other

words I don't want this to be this could

be a seminar this could be an entire

class probably which I'm not saying I'm

competent to teach but my

you hear is gonna be just that it's

gonna be somewhat superficial I'm gonna

kind of look at in survey issues but

it's going to be necessary certainly to

dive more deeply into these things I

might do that in future videos

but certainly you yourself are gonna

want to talk to advisors like doctors

possibly lawyers other people who might

be able to help you trusted friends and

family members who are going to help you

to think through and make decisions in

these very vital areas let me start with

this when is it time for a loved one to

go into a nursing home I'm gonna say

that I think actually this question

should really be understood to be two

distinct questions so the first question

I think that's really embedded in here

is the question of when does it become

necessary to give your loved one

intensive daily assistance care

supervision that's question number one

and question number two is going to be

when is it the case that that type that

level of assistance is no longer

possible to give them in their home or

in your own in other words when does it

become necessary to say the nursing home

is the only place that can effectively

deliver care to my love life those are

two distinct questions but to complicate

things further I think you can only

really begin to adequately answer those

questions if you take certain factors

into consideration it's probably any

number of factors that could be

mentioned here but I'm gonna mention for

medical logistical financial and

relational and I will explain what I

mean by those and hopefully it'll become

clearer as we move along but I need to

make the usual disclaimer I am NOT a

medical practitioner I am NOT a

financial adviser I am NOT a lawyer I

cannot give you specific advice on any

of the things that we're about to

discuss what I am talking about is an

overflow number one of my own

experiences that I had with my dad to a

lesser much lesser extent my grandma but

also research that I have done some of

it for the website but meant much of it

going back to the time period where I

was the primary caretaker for my dad and

had to make I had to make the decision

basically to put him into a nursing home

but let's take that first question when

does your loved one start to require

intensive daily care so notice that this

question concerns care level it's a care

level question so one obvious factor

that's relevant here is going to be

Medical Factor ideally we would like

then a way of gauging what the person's

medical need is now the long-term care

industry has certain terms and certain

metrics or at least they're working

towards a certain way of measuring this

and I'm gonna mention it here so in the

long term care lingo essentially your

loved one would require care intensive

long term care if he or she meets one of

two separate triggers the first trigger

is going to be physical so a physical

trigger in this one and I've mentioned

this in numerous other places but this

trigger essentially means that a person

would lack two out of six what are

called activities of daily living okay

they have to lack two out of six the

activities of daily living are things

like bathing yourself dressing yourself

feeding yourself being able to transfer

in and out of bed by yourself being able

to toilet by yourself and being able to

maintain bodily functions or be

Continent essentially is what it is that

is to say you have control over your

bladder over your bowels and so on now

once again these are physical triggers

they can be prompted by other conditions

other than Alzheimer's disease and as

good as these definitions are for the

long-term care industry they do depend

on doctor evaluations in ways that can

mean that whether a person lacks one or

other of these is going to be open to a

doctor's interpretation possibly several

doctors interpretations so once again

this underscores the need for you to

maintain a good level of dialogue with a

trusted circle of advisers including

those people who have a finger on this

kind of information presumably medical

practitioners and professionals of one

sort or other now the second trigger the

first Herger was physical the second

trigger is mental that is to say

cognitive impairment so in other words

you could lack two out of six activities

of daily living and be long-term care

certified or you could have a severe

cognitive impairment and likewise be

certified even if you contain yourself

feed yourself dress yourself and so on

cognitive impairment in this respect is

going essentially to be some kind of

severe deficit of cognition that is

going to affect a person's ability to

err for him or herself or that would

make them potentially a danger to

themselves or to other people if they

didn't have constant supervision

constant assistance so once again when

you lack the activities of daily living

you're gonna need daily assistance and a

person who is cognitively impaired to

such an extent that they essentially are

gonna need round-the-clock supervision

or whatever

also is going to be a trigger for

long-term care cognitive impairments in

view once again dementia or a deficiency

of memory which is obviously a symptom

of Alzheimer's disease not just that

there are other kinds of cognitive

impairment there are neurological

dysfunctions there could be traumatic

brain injuries there is other kinds of

dementia so for example there's

something called Lewy body dementia

there are any number of different

possible deficits and conditions that

might prompt the need for care and in

fact from the physical standpoint I mean

a person could lose continence in virtue

of some kind of a severe cognitive

impairment and that often happens

however a person could also lose

countenance for any number of other

reasons and I won't enumerate them but

there can be additional reasons for that

and similarly a person might lose the

ability to transfer in and out of bed

for any number of reasons they might

lose the ability to eat because they are

paralyzed for instance so there are any

number of different conditions that

might bear here but from a strictly

cognitive standpoint we're talking about

things like negatively effected

awareness decision-making judgment

memory perception reasoning almost all

aspects of what we call thinking

behavior emotional response all of these

can be negatively impacted now the

implications for such a cognitive

impairment are probably fairly obvious

to people who are watching the video

because they're they're dealing with

some of these right you're talking about

behaviors that are disruptive to the

household behaviors that are potentially

dangerous wandering sundowning certain

activities that might compromise

personal safety ideal in other places

with driving so a person who has such a

severe cognitive impairment that they

can no longer be trusted to even remain

in a safe place or they can't be trusted

to be able to care for themselves to not

electrocute themselves

not eat spoiled food to not turn the gas

on and forget that it's on to not wander

from the house and not remember how to

get back home these are the kinds of

things that people were living with

somebody with dementia face on a daily

basis and once they reach that critical

mass once that person's deficits start

to manifest in behavior that is

consistently pathological then it is

potentially time to start to weigh your

options obviously these considerations

bear on the safety of the person and

also frankly the safety of the other

people in the house I mean if my dad for

example had accidentally turned on the

gas or turned off the pilot light or put

dish detergent in the Sugar Bowl there

could be any other person in the

household who could be negatively

impacted because of those those things

and so this brings us to the second

consideration that I said the second

factor first was medical the second is

logistical so now remember the second

question I said when you're thinking

about the question when is a time for

your loved one to be in a nursing home

the first question is when does your

loved one require intensive daily care

that's the first question but the second

question was when can that care no

longer be reliably consistently safely

delivered in the home so in other words

when can your loved one no longer

receive their necessary care in the home

environment pertains in the first place

to the care environment now you have to

understand the Alzheimer's proof project

so my site my website Alzheimer's this channel in the first

place the concept that I had was twofold

the first was how to make changes in the

home environment in order to try to make

that environment safer a more effective

care environment for people who are

living with somebody who has dementia or

Alzheimer's disease so that was the

first meaning of Alzheimer's proof I

think of it as something like baby

proofing or child proofing a house when

expectant families bring a child into

the house they have to baby-proof it

well if you're caring for someone with

Alzheimer's you have to Alzheimer's

proof your house now the second meaning

is simply change us to your own personal

diet lifestyle to try and minimize your

risk but for the present purpose when

you think about those changes you might


make in your home environment which are

faced within is the prospect of making

your home environment more like a care

facility more like a nursing home

possibly like a hospital in various

respects and obviously you can't

completely convert the house into a

nursing home or into a hospital but

you're talking about adding additional

locks to doors maybe safety latches to

prevent your loved one from accessing

certain rooms from eloping I have videos

where I deal with adding certain devices

on to a door or on to an oven or on to a

microwave or on to a refrigerator to try

and prevent your loved one from

accessing things that he or she

shouldn't or can't safely this might

include things like adding closed

circuit TV cameras or other kinds of

cameras that you can access through your

smartphone might include monitors and

sensors or GPS trackers that you fit on

to your loved one to try to recover them

really in case they elope or wander away

from the house and those are all assists

to safety those are almost always going

to pertain to some cognitive deficit

there going to be an assist to the

caretaker to care for someone who cannot

be policed without them the second set

of logistical considerations has to do

with physical assists so these are

things like adding handrails grab bars

lighting possibly adding wheelchair

accessibility ramps widening the doorway

to accommodate a wheelchair or walkers

converting a bathtub to a walk-in in

other kinds of interventions that are

designed to give a person help from the

physical standpoint but to bring in now

my third consideration medical

logistical the third one was financial

first of all all of these contemplated

interventions cost money there are any

number of videos that I have on this

channel where I deal with paying for

long-term care how to get long-term care

insurance policies involved how to think

about paying for long-term care I've got

a lot of different content just on this

question so I don't want to make this

video overly long which it's already

running long in virtue of getting into

topics that I explore in more detail

elsewhere suffice it to say that from a

financial point of view you really only

have three ways to pay for long-term

care you pay out of your own income and

assets you pay until your income and

assets are spent down and you have to

and you're able to qualify for

government assistance or Medicaid or

you've never had any assets to begin

with and Medicaid is the only game in


and the third way so will private pay

Medicaid or number three proceeds from a

long-term care insurance policy those

are really the only ways to pay now

there are really two reasons why person

might want a long-term care insurance

policy the first of those is to protect

their assets so that they can be used

for legacy so they could be used for

survivor so if you have a spouse that

you want to be able to use your

retirement money you don't have to spend

it on one person's care you're gonna

need some way of protecting that asset

from having to be depleted in virtue of

paying for your for your nursing home or

for your homecare but the second reason

a person might want a long-term care

insurance policies to be able to

exercise greater control over where they

receive their care so for instance if

you have a long-term care insurance

policy and it provides for home care

then you take some of the burden off of

the care taker and we'll talk about that

in just a moment but you may be able to

stay in your home for longer than you

would have otherwise if your only care

taker let's say was your spouse your

spouse could be aging your spouse could

have cancer your spouse could be unable

to lift you or unable to cope with the

stress don't get me wrong there are

other strategies there are Medicaid

trusts for example but really that's not

a separate way to pay all the Medicaid

trust is is a way of handling your

personal assets to try to prevent them

from being used to pay for your

long-term care

you could also implicate a life

insurance policy here there's a couple

of ways to do that one is with writers

there are chronic illness writers there

are long-term care writers or say my dad

who was in a nursing home it was about

$300,000 for the four years he was in

the nursing home if my dad had privately

paid he didn't but if he had and if the

family had had a $300,000 policy

life-insurance on him we didn't but if

we had then that life insurance policy

would have in principle restored those

funds that we pay it on his care to the

family after he died now these are

complicated issues I cannot get into

them here there are many questions many

problems many difficulties here but for

further information I invite you to see

my other videos where I deal more in

detail with those questions but the

final point that I want to make the

final of

the four factors that I mentioned so

medical logistical financial and the

fourth one is relational I can't think

of a better way of putting this except

to just say this is the point where

you're dealing with other people other

people in your life your spouse your

family your children your friends

perhaps and there are some tips that I

have to at least suggest you one is plan

early now for many people watching this

video it might be too late because

you're coming to this video because

there's somebody right now who has these

problems you can't you can't go back in

time and plan early but you can take the

lessons for example the lessons I

learned from my experience with my dad

the lessons that I learned I'm trying to

apply to my life in hopes that I can

help my children avoid having to go

through the same thing with me that I

went through with my dad the second part

of this is in order to plan early you're

gonna have to have frank discussions you

cannot Oscar it you can't put your head

in the sand and refuse to talk about

issues with respect to end-of-life care

or the possibility of long term care

because if you do that you're not doing

a service to any of your loved ones or

to yourself another thing that I would

say is only make promises that you can

keep if you're gonna promise your loved

one that they will never have to go into

a nursing home only make promises that

you are prepared to keep and from the

flipside of that only ask for promises

that you are prepared to lay on the

person that you're asking it from

another make no mistake about it asking

a person to commit possibly a decade of

their life five years ten years whatever

it might be to care for you in a home

environment an order that you don't have

to go into a nursing home it's it's

Noble and I can't tell you not to do it

I can't tell you to do it I'm not

telling you what promises to make or not

make I'm only saying you have to realize

it's a gravity of what you are asking

caretaking duties take a tremendous toll

on the caregiver they can negatively

impact almost every aspect of a person's

life they can negatively impact a job

some people might be in a position of

almost losing their job because they

have had to devote time to caretaking

they might be in a precarious situation

financially it's possible that children

spouses grandchildren are kicking money

in to try to pay for certain aspects of

a loved one's care that maybe they can't

otherwise afford it can negatively


the health of the caretaker can

negatively impact their life expectancy

it can cause them physical injury

lifting a person from the a bed to take

them into the bathroom or to try and get

them in and out of a bathtub or to try

and wipe their butt when they make a

mess or to try to bathe them when like

my dad was he was irritable agitated

much of the time he was belligerent

none of these are easy tasks this can

cause enormous stress enormous anxiety

frankly and here's a bit of a personal

thing I was physically sick many days

worrying about what my dad might do that

day what I might have to do I was

advised and I won't say by who but by a

trusted organization to contact the

police department when my dad got out of

hand and I remember the first time I

actually had to do that or I felt like I

had to do it and the police showed up

and they essentially looked at me

dumbfounded like what did you call us

for what do you want us to do my dad was

simply out of control in the house and

the police wanted to know what do you

want us to do I mean you want us to

arrest your dad you want us to taser him

I mean they they it was obviously a very

awkward situation simply the police

presence in the house call my dad down

because as far gone as he was in terms

of his impairment he still had an innate

respect for authority I suppose but at

the same time I realized in virtue of

that that I couldn't just call the


every time I dad got agitated like that

and so it really caused me to become

sick because I didn't know what was I

supposed to do you know handcuff my dad

to the bed and then there can be

enormous and guilt one of the most

haunting images that I have frankly is

the image of my dad being driven away

from the house me knowing that he was on

his way to a nursing home to be put into

the nursing home essentially for the

rest of his life I mean you don't

necessarily think about it like that

because it's too painful to think of it

like that but you realize he's got

Alzheimer's disease it's a progressive


he's already unable to be cared for in

the home you realize this is a one-way

ticket and I had nightmares about him

coming back to

house because it was so riddled with

difficulty and and stress and I had two

children small children in the house at

the same exact time and so I felt

horrible that I couldn't do more for my

dad but at the same time I was petrified

that I would be in the position again

even when my dad was in the nursing home

so it just is a psychological mess it's

a mess it is hard enough to make an

objective good decision based on facts

about the care environment and facts

about the home environment it's hard

enough to do that from an objective

standpoint without factoring in all of

these psychological aspects which they

can't be eradicated essentially let me

just say a few words in summation the

issue is not easy it's difficult to get

a handle on you're gonna have to do

essentially just think about some of the

pros and some of the cons it's going to

matter the answers to those questions

when do they start needing daily care

when is it not possible any longer to

provide that care in the home is it even

possible at all to provide care given

their home environment or your home and

right if it isn't then you have at least

the makings of an answer you're either

gonna have to make changes to your home

environment or you're going to have to

look for an alternative environment now

of course in principle some of the pros

that go along with a nursing home are in

principle that the home is going to be

safe it's going to be secure it's going

to provide them with skilled care that

they desperately need in theory in

practice many nursing homes are

substandard in a variety of ways they

are understaffed many of the people are

overworked they tend to over medicate

they're underpaid this can lead to a

lack or a deficit of attention on your

loved one it can even make it the case

and some people's judgment that your

loved one might decline faster in a

nursing home than they would decline in

another environment because no one loves

your loved one like you do that doesn't

mean you can't be involved so you want

to keep that in mind as well but the

other major factor here is going to be

cost what is going to be the impact in

terms of finances do you have resources

is Medicaid the only game in town for

you and if it is then you have to

realize Medicaid is going to limit the

location where you're going to be able

to find a nursing home that takes

Medicaid has an open Medicaid bed

and possibly you're gonna be faced with

waiting lists for certain nursing homes

and you may end up having to put your

loved one in a location that's not ideal

that's not located close to you there

are so many different factors here again

I told you this was going to be a

whirlwind I'm sorry that I got as long

as it has obviously the very final thing

that I'll say is clearly we want to try

and make a decision that is in the best

interest of our loved ones we want to

think about it in terms of objective

interest in terms of where are they

going to receive the best care available

but at the same time I recognize that

not everybody there's gonna be different

ways of weighting factors here if you

have made a promise to your loved one if

you know that he or she would be

uncomfortable outside the home

environment and you want to make every

effort to try and accommodate their

wishes I respect that totally but you

have to realize the difficulty involved

and I'm sure you many people do but at

the same time recognize that there are

other people in the same position that

you are and part of the entire thrust of

the Alzheimer's proof project is trying

to assist you it's trying to assist you

in order to keep that promise in order

to make your home environment as safe as

possible now is it gonna cost money yeah

unless it's good unless you have some

handyman or carpenter and your family or

unless you yourself were able to perform

some of these interventions it's going

to cost money no matter where they

receive their care you may have to at

some point reach out to other people you

may even have to bite the bullet and

actually put them into a nursing home if

you can no longer reasonably meet your

obligation because you have to remember

too that it not only doesn't impact your

health but obviously if they are

receiving substandard care it's not

doing anybody any good this is obviously

a very very tough issue so I hope that's

something that I said was of help to you

I hope maybe it got your thinking going

I hope it provided an answer possibly

that you were looking for I am going to

try and make videos possibly touching

and going more deeply into some of the

other things that I've discussed but

this video I need to wrap it up I thank

you for watching I invite you to check

out some of the other content that I've

done and all I can really say is I wish

you the very best in making this

decision the