When Family Members Care for Aging Parents

Republished from: https://www.nytimes.com/2018/09/19/well/live/when-family-members-care-for-aging-parents.html

By Sandeep Jauhar

Sept. 19, 2018

My siblings and I joined the ranks of the 15 million or so unpaid and untrained family caregivers for older adults in the United States.

I hadn’t realized how quickly my father’s mind was fading until one morning a few years ago when he asked me why he was taking only six medications per day. “What will I take on the seventh day?” he wanted to know.

My mother, who had been given a diagnosis of Parkinson’s disease, had been in decline for some time and could be of limited help. Anti-Parkinson’s medications helped to relieve her muscle rigidity, but her condition had continued to worsen.

So we pressed my father to retire his professorship so that the two of them could move from Fargo, N.D., to Long Island to live closer to me and my brother. When my parents arrived, it was alarming how much their conditions had deteriorated.

My father was forgetful; my mother required assistance with walking. The friend who helped them move took me aside after they arrived. “They have to have hope,” she said.

“Hope for what?” I asked.

“That one day they will be able to do the things they can’t right now.”

We wanted our parents to live independently in their own home, which meant that my siblings and I were going to have to chip in to help. It was a small price to pay, we thought. When my sister visited from Minneapolis, she bathed and dressed my mother. I administered their medications and helped with groceries. My brother took care of household issues. Still, my parents’ home, like my parents themselves, was in a constant state of disrepair.

That summer, my siblings and I joined the ranks of the 15 million or so unpaid and untrained family caregivers for older adults in this country. A recent study found that almost half of this largely invisible work force spends, on average, nearly 30 hours a week providing care to relatives, many of whom have dementia, an estimated more than $400 billion worth of annual unpaid time.

The work takes its toll. These sons, daughters, husbands and wives are at increased risk of developing depression, as well as physical and financial difficulties, including loss of job productivity. Being sick and elderly in this country can be terrifying. Having a sick and elderly loved one is often a full-time job.

As the workload increased, we hired help, as much for ourselves as for our parents. But after some items were stolen, we realized we had to be more careful about whom we allowed into our parents’ home. Older adults in this country lose almost $3 billion a year to theft and financial fraud. Nearly every week my father instructed us to donate money to someone who had sent him a generic email appeal. It fell on us to keep our parents from being exploited.

With millions of elderly adults requiring assistance with daily living, physicians should make it routine practice to ask family members whether they can provide the requisite care. Many of these potential caregivers, ill or stressed themselves, simply cannot.

Insurers should also set aside funds to support these caregivers. Family members are often the people most invested in the care of their loved ones. Supporting them will only benefit our most vulnerable citizens. It won’t be cheap, of course. Because of the size of this unpaid family work force, even providing minimum wage to the most taxed caregivers could cost up to $100 billion annually.

In 2015, Andrew Cuomo, governor of New York, announced a $67.5 million grant to help ease the burden of informal caregivers of dementia patients in the state. The money pays for counseling, support groups and a 24-hour hotline. It also subsidizes the hiring of friends and neighbors at $15 an hour so that family members can enjoy occasional respite from the strain of caregiving. Several other states, including North Carolina, North Dakota, Minnesota and Vermont, have similar programs but on a much smaller scale. Much more needs to be done nationally.

Though our parents’ independent living required a steadily increasing commitment, there was no dearth of moments to remind us that it was worth it. I once called my father to tell him I was going to stop by the house later to talk about a change in one of her medications that her doctor had suggested.

When we ended the conversation, he forgot to hang up the phone. I heard him turn on the TV, which was playing a popular Hindi film song.

“Will you listen to some music with me?” he asked my mother. She did not reply. “Come on, hold my hand,” he said.

“No one has any use for me,” I heard my mother say.

“I do,” my father said. “The kids do. Here, hold my hand and dance with me.”

Sandeep Jauhar (@sjauhar), a cardiologist, is the author of “Intern,” “Doctored” and the newly released “Heart: A History.”

I Had Alzheimer’s. But I Wasn’t Ready to Retire.

https://www.nytimes.com/2018/09/07/opinion/early-onset-alzheimers-work.html

By Wendy Mitchell
Ms. Mitchell is the author of a memoir about dementia.
Sept. 7, 2018

“How long have you got?”

This is what my boss asked me when I informed him, in July 2014, that I had early-onset Alzheimer’s.

I had a file an inch thick with suggestions for how I would be able to keep my job as an administrator with the British National Health Service, one I had loved for more than 20 years. Whether out of panic or ignorance, my manager didn’t see it that way. A date for my early retirement was inked into his calendar; I would leave eight months later due to “ill health.”

I was 58 when I learned I had early-onset Alzheimer’s. For two years, I had been experiencing short-term memory loss. I sometimes had difficulty finding the simplest of words — I once forgot the word “and” in a meeting — and I’d been struggling to concentrate. While the diagnosis made sense to me, it was devastating.

Still, I hadn’t expected it would sound a death knell for my employment. I had new challenges, but I was still a capable employee who brought, I believed, a lot to the table. Besides, I worked for a health system that prided itself on understanding a patient’s needs. But here it was forgetting to extend the same compassion to an employee.

People are living and working longer than ever, and that means the incidence of people in the workplace with early-onset dementia will increase. In Britain, more than 40,000 people under the age of 65 have dementia. In the United States, there are an estimated 200,000 with early-onset Alzheimer’s.

Employers can’t just write them off. Loyal employees are a valuable resource. They’ve been trained (presumably at the expense of their employer) and have probably, in turn, trained others. They have a valuable understanding of their jobs. Employers need to realize that knowledge doesn’t just disappear overnight; this is a progressive, and often slow-moving, disease. I was still the same person I was the day before I received my diagnosis. I just needed to tackle my job — and my life — in a different way.

In the time I was given to stay on at work, I made adaptations. It turned out that my colleagues were much more understanding than management. They took the time to think and talk to me about what support I needed from them to keep going.

We got creative: They created a color-coded Post-it note system, with each color denoting a different team member, to help me remember whom to get back to on which project. They also knew to email me questions instead of popping their head into my office and expecting an immediate answer.

When I worked from home, the team would contact me only at prearranged times so I would know when I’d be interrupted. I’d set an alarm five minutes before that time, which alerted me to finish any task I was working on and prepare for the incoming call. When I was no longer able to recognize voices on the phone, email still served us well. Or they waited for me to be in the office; face to face and one at a time, I could manage things better.

I recently read about one woman’s happier experience with her employer, the British supermarket chain Sainsbury’s. As her dementia took hold, her managers worked with her, cutting her hours and duties where appropriate. They realized that she still had a contribution to make, even though it might have been a dwindling one. Her son praised the company on Twitter, writing that his mother’s “sense of self-worth and pride has undeniably helped with aspects of her Alzheimer’s.”

I no longer work for the National Health Service, but I still have time and energy to spare. I now work with several dementia charities and support organizations, and regularly speak about my experience with Alzheimer’s disease to audiences of doctors, nurses and caregivers. I try to communicate all that we patients still have to contribute to society. It feels good to have my opinions valued and my story heard. It has lifted my spirits, and I believe my packed schedule keeps the disease at bay.

I look back sometimes and wonder how things could have been different if my manager had really talked to me, if he had leaned across his desk and said, “Wendy, you have always been an asset to my department; now it’s my turn to help you.” How much longer might I have been able to keep working? What else might I have gone on to achieve?

Had I been given a chance, my response to “How much time have you got?” would have been, “I’ve got as much time as you will give me.”

Wendy Mitchell is the author of the memoir “Somebody I Used to Know.”

To Manage Dementia Well, Start With The Caregivers

Republished from:  https://www.npr.org/sections/health-shots/2018/09/15/647992785/to-manage-dementia-well-start-with-the-caregivers

Lauren Gravitz
September 15, 2018

When Kate Sieloff's husband, Karl, began acting strange, she didn't know where to turn. Her hard-working, affectionate spouse was suddenly having fits of anger and aggression. He stopped paying the bills. Karl, 56 at the time, was an engineer at General Motors, where he'd worked for more than 40 years. But some days he didn't even show up for work, finding it too hard to get out of bed.

Because the problems were sporadic, most people in her life couldn't see what was going on. They told Kate, of Romeo, Mich., that she was imagining things. Doctors suggested that Karl was depressed and tried him on a variety of medications. When he began depleting their savings on impulsive purchases, and grew even more aggressive and violent, her son—a neurologist at the University of Michigan's medical center in Ann Arbor—insisted she bring Karl to his hospital for evaluation. Doctors there quickly diagnosed him with frontotemporal dementia.

For Kate, the diagnosis was a relief, but she still felt overwhelmed and needed help coping with her husband's illness. Getting his diabetes medications under control, and starting him on a mood stabilizer and a new antidepressant helped control his mood swings while restoring some of his loving personality.

But there is no drug that can prevent or stop the eventual progression of dementia. What she needed was something that could help make her day-to-day caregiving more tolerable, and strategies to help him when the confusion set in.

Things changed when she and Karl went to see Helen Kales and her team at the Program for Positive Aging.

Kales, a geriatric  psychiatrist who practices at the University of Michigan, in Ann Arbor, has developed a behavioral approach to dementia care, one that puts the caregiver first and emphasizes training and support for them as much as for the patient. By teaching caregivers new ways to solve old problems, and to respond to their own needs in as well as those of their loved ones, the approach helps ease their burden while simultaneously improving the patient's experience. It's a bit like airplane safety rules directing passengers to put on their own oxygen masks before helping someone else.

One of the most important aspects of caring for someone with Alzheimer's and other dementias is understanding the diseases. The difficulty, Kales explains, isn't the memory loss, per se, but the behaviors that accompany it — everything from anger to petulance to violence to depression.

"We think about dementia as a problem with memory, but it's really behavioral," says Kales. "If you look at the medications being used, they're all psychiatric and used to managed behavior: antipsychotics, antidepressants, and sleep medication. Anxiety medication. We even use mood stabilizers."

Yet despite the millions of dollars spent on these drugs, she says, study after study has shown that their efficacy in treating dementia is typically quite small.

Rather, research suggests that it's far better to use behavioral and environmental approaches — ones that are sensitive to, and focus on, the needs of a patient, Kales says. "Particularly when you train family caregivers to deliver them in the home."

As more people survive into their 80s and 90s, there are more people living with Alzheimer's and other dementias than ever before. And the burden is one that primary-care physicians can't handle alone.

"We realized we needed to do something different," Kales says. "We just can't train enough physicians to provide dementia care. Instead, we need to take the daily treatment and management of these patients out of the hands of physicians and put it into the hands of the caregivers themselves."

It's an important move. Researchers have shown that the majority of people with dementia are cared for at home by members of their family. And that those family members, in turn, have higher incidence of stress and depression, as well as lower overall quality of life.

"The trick seems to be in training family caregivers to spot triggers of behavior and problem-solve around those triggers, to look for underlying causes and then creatively develop strategies," Kales says. But such approaches are rarely employed because there's no systematic way to teach people how to use them.

That's where Kales' DICE approach comes in. The method — an acronym representing the four main steps of the process — trains those who look after people with dementia to thoughtfully address behavioral issues. Those steps are: Describe a behavior, thinking about what happens and the context in which it occurs; Investigate its possible causes; Create and implement a plan to address the behavior; and evaluate the results to determine what worked.

No one had ever provided family caregivers with such a user-friendly method before, says Katie Brandt, the director of Caregiver Support Services for the Frontotemporal Disorders Unit at Massachusetts General Hospital, in Boston.

"[Kales] took theories about dementia care and behavior management and turned it into a step by step approach that people can apply," she says.

Here's how it can play out. Ideally, instead of giving someone a Valium because they're particularly cantankerous, caregivers would look deeper, analyzing the behavior to figure out why it's occurring. This can take extra effort when dealing with a patient who can't communicate in a linear way, or at all, about their experience. In this and other ways, it's not unlike caring for an infant.

As an example, Kales points to one of her patients, who came into the clinic with his daughter. The daughter mentioned that her dad had been extra ornery that morning, swatting at her as she tried to get him into the car. A physical exam showed that he was experiencing pain in one of his arms, so Kales sent him for an X-ray, which revealed a torn rotator cuff.

"Someone could cover that over with a medication, sedate the gentleman, and he'd continue to have the painful, pathological condition that requires treatment," she says.

Often, caregivers are given list after list of things they could do to make a house safer or a day of caretaking go more smoothly. But, Kales says, "None of those approaches are really effective for all people. The solution is really in the tailoring of the approach to the symptom, the situation, the caregiver."

Kales's clinic has had success teaching DICE to their caregivers. And for Sieloff, the difference has been life-changing. She's learned to better understand her husband's dementia, to help him stay calm and feel in control, and to create solutions for some of his more irascible moments.

With the program's help, she has taken control of her finances, applied for different kinds of assistance, and come up with practical ways to help Karl: a daily routine with limited choices; activities, such gardening, that hew to his interests; and small cards that say, "Please understand my husband has dementia," which she can hand strangers to de-escalate moments when his anger gets out of control.

Beyond that, working with people in the program has helped her own state of mind. Before her husband's diagnosis, family members and even some therapists had blamed her for Karl's problems, or believed she was making them up. "I needed to be absolved," she says. "For the longest time, people told me it was my fault and I felt so much guilt. I wasn't sleeping at night. Now I'm sleeping well."

The University of Michigan team hopes to make such help universally available. They're creating publications and online tools to help those outside their clinic, and just published the first pilot study of a web-based DICE tool called WeCareAdvisor. For the study, caregivers answered a series of questions online and the tool selected from nearly 1,000 strategies to create a behavioral "prescription" for them to try. If the new strategies didn't help, they ran through the process again, testing new approaches. They also received an informational resource on dementia and daily messages of encouragement and motivation. At the end of the month-long trial, caregiver distress had decreased significantly.

Brandt has seen similar results teaching DICE in the Boston area. "We know that care-giving is a threat to your health," Brandt says. "And caregiver stress not only impacts the quality of life of the caregiver, but also impacts the quality of life and quality of care of the person living with dementia."

After coaching caregivers in her clinic, she says that it appears to reduce stress, while helping them feel confident and more prepared for the challenges that pop up. Massachusetts General Hospital is now looking to adapt Kales WeCareAdvisor, which was developed primarily with caregivers of Alzheimer's patients in mind, for use in frontotemporal dementia.

Kales says that a printed DICE manual should be available for sale at the end of October and an interactive website—which will contain video modules and e-simulation trainings—at the end of November.

As far as Seiloff is concerned, the sooner the better. "I can't imagine where I would be without the DICE clinic," she says. "It's given me a whole new life. I'm trying to tell everyone I know about this."

Lauren Gravitz is a science writer and editor. Her work has appeared in Nature, The Economist, Aeon, Discover, The Oprah Magazine, and more. Find her at www.laurengravitz.com and @lyrebard.com

The Long-Term-Care Insurance Dilemma

Premiums keep rising, but you may need a policy more than ever.

By KIMBERLY LANKFORD
Contributing Editor
April 4, 2018
From Kiplinger's Personal Finance

One of the most effective ways to protect your retirement savings from the high price of assisted living, in-home care or a stay in a nursing home is a long-term-care insurance policy. But recent premium hikes have many baby boomers worried that coverage is no longer affordable.

The median cost of one year in a private room in a nursing home was $97,500 in 2017, according to Genworth's Cost of Care Study. A year of assisted living was $45,000, and 44 hours per week of home care–which most people prefer–came to $49,000. Care costs have been going up by 3% to 4% per year over the past five years.

Those rising costs have put pressure on long-term-care insurers. Rates have spiked by at least 50% for most policies purchased between the mid 1970s and 2005, with some price hikes topping 100%. Almost every long-term-care insurer has raised rates at least once, and more rate increases are on the horizon, depending on the insurer and the state.

Policies with lifetime benefits and 5% inflation protection have been hit the hardest. For example, Mike Ashley of Prairie Village, Kan., purchased a Genworth policy 19 years ago, when he was 52 years old. He paid $879 per year for a policy with a $70 daily benefit, 5% inflation protection and lifetime benefits. After two rounds of rate increases, his premiums had climbed to $1,547 per year.

Insurers admit they made major mistakes when pricing these policies. They expected more people to drop coverage, overestimated the interest rates they'd earn on their investments, and underestimated the size and length of claims.

What to do. Fortunately, there are ways to make long-term-care insurance more affordable. Don't drop your policy if you're faced with an increase; new coverage will cost a lot more. Although Ashley's annual premiums increased by more than 75%, he's 19 years older and his daily benefit has grown by 5% a year. A new policy for a 71-year-old with similar features and coverage would cost at least $9,000 a year. If you can't afford the higher premiums, your insurer will generally give you several options. For example, you may be able to minimize the rate increase if you cut future inflation protection from 5% to 2.5% or 3%, says Claude Thau, an insurance consultant in Overland Park, Kan.

If you haven't bought a policy yet, you can still find coverage that protects a big portion of your retirement savings while keeping the premiums affordable. One option is to figure out how much longterm care your retirement savings and income will cover and use insurance to fill the gap.

You can trim the premiums not only by buying a policy with less inflation protection but also by selecting a shorter benefit period. For example, Ashley cut his premiums to $1,384 by reducing his lifetime benefit period to a six-year period. A 55-year-old couple could pay less than $3,500 per year (combined) to buy a new pair of policies that provide each spouse with a $150 daily benefit, 3% inflation protection and a three-year benefit period (couples buying together get a significant discount).

Insurers have learned from their pricing mistakes and shouldn't have to increase premiums on new policies as much in the future. Still, you should factor in potential increases when calculating how much insurance you can afford. John Ryan, of Ryan Insurance Strategy Consultants in Greenwood Village, Colo., recommends planning for a 20% increase every 10 years.

Seniors Healthier When Medical Care Is Coordinated

Reprinted from: bit.ly/2ogyMb6 and bit.ly/2odAjP9 CMAJ, online August 27, 2018.

By Linda Carroll

(Reuters Health) - As America’s population ages, experts are exploring how best to keep older people with multiple chronic illnesses healthy. A new study suggests that coordination between physicians may be key.

In a reanalysis of 25 earlier studies including 12,579 patients, researchers found that coordination of care for older adults with multiple medical conditions resulted in improved health. Patients in the study had combinations of disorders such as heart failure and obstructive lung disease, arthritis and depression, diabetes and depression, or diabetes and cardiovascular disease.

Currently more than 62 percent of older Americans have multiple chronic conditions, the researchers noted in CMAJ. And many of those seniors receive care from a variety of specialists who don’t communicate with one another.

“To address the challenges faced by our rapidly aging population, we need to focus on a more patient-oriented and holistic strategy that targets management of patients with common disease combinations, such as diabetes and depression, rather than treating one disease at a time,” said study leader Monika Kastner, a health services researcher at the University of Toronto, Canada, and research chair at North York General Hospital.

Care coordination, Kastner explained in an email, can be defined as efforts by health care professionals to facilitate and coordinate appropriate, timely and efficient delivery of health care services for a patient.

The average age in the studies was 67. One area where coordination made a big difference was in patients who had a chronic physical condition along with depression. For example, patients with both depression and diabetes had improvements in both depressive symptoms and blood sugar levels when they got coordinated care.

The new article “takes us in the right direction,” said Michael Wolf, associate vice chair of research in the department of medicine at Northwestern University’s Feinberg School of Medicine in Chicago.

Wolf has personal experience with a problem that’s common when care is fragmented: the possibility that doctors will provide a patient with overlapping medications.

“My sister at one point was on 24 medications,” he said in a phone interview. “It wasn’t till she was hospitalized that a surgeon pointed out that she was taking multiple medications to treat the same thing. They had been prescribed by different people. When she left the hospital, the number had been reduced to six or seven.”

Presently, however, there is no template to show health care providers how to accomplish coordinated care with the system set up the way it is, Wolf pointed out.

There are a number of reasons why patients rarely get coordinated care, said Dr. Alicia Arbaje, director of translational care research in the division of geriatric medicine and gerontology at Johns Hopkins University in Baltimore, Maryland.

Top on the list is the way practitioners are reimbursed, Arbaje said by phone. And beyond that, “we haven’t caught up in our training of physicians to learn how to work with other providers or even as a team,” she added. “Also, we don’t have a culture of accountability. In the culture we have, once a patient is out of the hospital, that patient is now someone else’s responsibility. And the same is true outside the hospital.”

Patients often assume that their doctors are all on the same page, Arbaje said. “I think some levers could get moved if there was some outrage from the public,” she added. “People asking why isn’t care done this way.”

Take a Look at These Unusual Strategies for Fighting Dementia

Reprinted from: https://www.nytimes.com/2018/08/22/world/europe/dementia-care-treatment-symptoms-signs.html

NETHERLANDS DISPATCH
By Christopher F. Schuetze

Aug. 22, 2018

DOETINCHEM, Netherlands — “We’re lost,” said Truus Ooms, 81, to her friend Annie Arendsen, 83, as they rode a city bus together.

“As the driver, you should really know where we are,” Ms. Arendsen told Rudi ten Brink, 63, who sat at the wheel of the bus.

But she was joking.

The three are dementia patients at a care facility in the eastern Netherlands. Their bus ride — a route on the flat, tree-lined country roads of the Dutch countryside — was a simulation that plays out several times a day on three video screens.

It is part of an unorthodox approach to dementia treatment that doctors and caregivers across the Netherlands have been pioneering: harnessing the power of relaxation, childhood memories, sensory aids, soothing music, family structure and other tools to heal, calm and nurture the residents, rather than relying on the old prescription of bed rest, medication and, in some cases, physical restraints.

“The more stress is reduced, the better,” said Dr. Erik Scherder, a neuropsychologist at the Vrije Universiteit Amsterdam and one of the country’s best-known dementia care specialists. “If you can lower stress and discomfort, it has a direct physiological effect.”

Simulated trips in buses or on beaches — like one in a care facility in Haarlem, not far from a real beach — create a gathering point for patients. The shared experience lets them talk about past trips and take a mini holiday from their daily lives.

Dementia, a group of related syndromes, manifests itself in a steep decline in brain functions. The condition steals memories and personalities. It robs families of their loved ones and saps resources, patience and finances.

Up to 270,000 Dutch people — roughly 8.4 percent of the 3.2 million residents over the age of 64 — have dementia, and the government expects that number to double in the next 25 years.

In recent years, the government has preferred to pay for home care rather than in a licensed facility so most people with dementia live at home. The facilities, which are privately run but publicly funded, are generally reserved for people in an advanced state of the disease.

In the 1990s, the Dutch started thinking differently about how to treat the disease, moving away from a medicalized approach.

“In the ’80s, clients were treated like patients in a hospital,” said Ilse Achterberg, a former occupational therapist, who was one of the pioneers of “snoezel” rooms, which feature light, aroma, massage and sound therapy, and let patients relax and access emotions that are often blocked in stressful clinical settings.

These rooms were the forerunner of some of the techniques found today in many care facilities in the Netherlands.

At the Amstelring Leo Polak home in Amsterdam, for example, there is a reproduction of a city bus stop, where Jan Post, a 98-year-old patient, often sits and kisses his wife, Catharina Post, when she visits.

Mr. Post, who has severe dementia, can create only 10 seconds of short-term memory and is afraid of not finding his way back to his room when he leaves it.

“Seventy years married and we are still in love,” said Ms. Post, 92, who visits several times a week.

The Posts were drinking and chatting recently at Bolle Jan, a re-creation of an actual Amsterdam cafe in a common area of the home.

If the surroundings were fake, the alcohol was real, and the jokes, often repeated, drew real guffaws. The singing, at times wobbly, was enthusiastic.

While caregivers and academics believe that such environments help dementia patients cope better, solid evidence for their long-lasting effectiveness is hard to come by, in part because the condition has no cure.

But Katja Ebben, who is the intensive care manager at Vitalis Peppelrode, a home in Eindhoven, in the southeast of the country, said she had noticed that with the newer techniques, patients need less medication and fewer physical restraints.

Willy Briggen, 89, who is in an advanced stage of dementia, lives at the Eindhoven home.

Like many with dementia, Ms. Briggen sometimes becomes impatient, even unruly. The outbursts put a strain on the home’s staff, who struggle to deal with her frail frame. A decade ago, she might have been prescribed drugs or restrained to manage the outbreaks.

But when she gets upset, the staff rolls a squat projector into her room, where it beams out calming images and plays soothing sounds.

On a recent visit, Ms. Briggen went from an obvious state of emotional discomfort to calm reflection as she gazed at the ceiling of her private room, which was festooned with projected nature scenes, including of ducks.

Of the 210 residents at the Eindhoven home, 90 have dementia and are restricted to special floors for their safety.

The brick-and-glass building has linoleum floors, low ceilings and wide doors to accommodate beds on wheels. Despite the medical style, its décor has echoes of a bygone era, when Ms. Briggen would have been a girl.

The floors feature old-fashioned, dark-wood furniture, and the rooms are decorated with books, rotary-dial phones and 50-pound typewriters. The cafeteria’s tables are covered by tablecloths and freshly cut flowers. It does not smell like a hospital.

In rethinking how to deal with dementia patients, many care centers have focused on the surroundings. Another tactic is to reorganize residents to create “family” clusters of six to 10 people.

Residents in many Dutch facilities have their own rooms, which they are encouraged to view as their own domain. There is often a communal living room and a kitchen, where residents help with chores like peeling potatoes and washing salad.

In the fight against depression and passivity, which are often symptoms of the condition, care givers also try to stimulate residents with activities like dancing.

“It’s really about all the little things that make a normal life,” said Pamela Grootjans, a nurse at Sensire Den Ooiman, the facility in Doetinchem that offers the simulated bus ride.

In the Christian Beth-San special care home in Moerkapelle, close to The Hague, Arie Pieter Hofman, 87, and Neeltje Hofman-Heij, 88, use a simulated bike connected to a treadmill to race through scenes from their old neighborhood in Gouda, projected onto a flat-screen display.

The company that makes the bike tour, Bike Labyrinth, has sold the simulators to more than 500 homes in the Netherlands. The Dutch maker of the projectors, Qwiek, says it has units in 750 Dutch care homes.

“The idea is to challenge the patient a bit in a positive way,” said Dr. Scherder, the Amsterdam neuropsychologist. “Leaving them in the chair, passive, make the disease progress much faster.”

On a recent visit to the Vreugdehof care center in Amsterdam, one resident, Anna Leeman-Koning, 90, played with a therapy robotic seal. It helps brings old emotions to the fore, momentarily sweeping away disorientation caused by the resident’s irreversible, progressive loss of faculties.

But the seal began shaking its robotic tail too much, upsetting Ms. Leeman-Koning.

“Please calm down, please calm down,” she said. “What can I do to calm you down?”

Medicare Skilled Nursing Facility Coverage

You do not have to improve to qualify!

Coverage Criteria

3-Day Inpatient Hospital Stay

1.       You must have a qualifying three-day inpatient (as opposed to outpatient) hospital stay. Medicare Advantage plans might not have this requirement.

2.       Generally, a transfer to a skilled nursing facility must be made within 30 days of leaving the hospital.

Physician’s Order

1.       Your care at the skilled nursing facility must have been ordered by a physician and must relate to a condition for which you received inpatient hospital services or that arose at the skilled nursing facility while being treated for a condition for which you received inpatient hospital services.

2.       As a practical matter, the care must only be available on an inpatient basis.

Daily Skilled Care

1.       You must require and receive skilled nursing seven days a week, skilled therapy five days a week, or a combination of both skilled nursing and therapy services seven days a week.

2.       Skilled care means that services must be provided by, or under the supervision of, a skilled professional in order to be safe and effective.

No Improvement Standard

1.       Medicare coverage “does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care. Skilled care may be necessary to improve a patient’s condition, to maintain a patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.” CMS Transmittal 179, Pub 100-02, 1/14/2014; Medicare Benefit Policy Manual, Chapter 8, Sections 30.2, 30.3.

100-Day Benefit Period

1.       Your maximum benefit period is 100 days. It is possible to have more than one benefit period during the calendar year.

2.       You are entitled to notice and to file an appeal when your Medicare-covered skilled nursing facility care is terminated before the end of your benefit period.

For additional information, see the Center for Medicare Advocacy’s Improvement Standard Homepage.