Reaching a Balance

Important issues in nursing home placement

By: Dr. Nestor H. Praderio, M.D.

What do we do with the pain, discomfort and anxiety of placement issues?

“I remember the ache in my heart as I left my father in the nursing home, and the ongoing conflict I felt when I visited him every week,” said one family member/caregiver. “Caregiving doesn’t end when you move someone; it just changes.”

When you share the diagnosis of an Alzheimer’s disease, regardless of the stage of the disease, you start a journey: the physician, the family and the patient. There is no doubt that in order to be successful, we need to reach some balance. We cannot stress ourselves to where the placement issues become a chaos of fears and we become dysfunctional.

The first pathway to placement is from the hospital. Half of the patients who come to me for care do not come to my office. I meet them at the hospital for acute hospitalization. The other half of the patients will return home with a treatment plan change.

While we are in my office with the patient, we start thinking that a pill is not going to be enough. There is no cure for dementia. Therefore, we need to enhance service, and we decide that we want some help from the community.

In this process, we start talking to family members about some of the markers that we believe need to be kept in mind for future placement. How does one make such a decision and what should be considered? Problems that most frequently lead families to decide are:

• Caregiver burnout
• 24-hour care required
• Severe memory loss
• Incontinence with inability to transfer
• Unsafe behaviors and wandering
• Inability to take medications

There are different levels of intervention, which is decided by necessity.

Emotional factors in nursing home placement:
• Communicate and talk with your loved ones
• Channel your efforts into selecting the best possible home
• Think of added care and benefits your family member will receive
• Be realistic, and recognize personal and financial limitations

Recognize the positive of a timely placement:
• People adjust well up to 89 percent (three months)
• 24-hour-a-day care is available
• Social activities and a sense of community is therapeutic
• Family with more energy devote more emotions in caring

There are some predictors of how individuals are doing on the way to nursing home placement. We take into consideration:
• Patient demographics
– Married elders less likely to enter placement (pointing to the importance of spousal caregiving)
– The relationship of the caregiver to the patient (less likely with wife or child)
– Caucasians compared with Hispanics and African Americans have had higher rates
– Older age is a risk factor for placement

• Caregiver characteristics
– Perceived stress or burden (key predictor)
– Health problems
– Age
– Lack of family support
– Lack of appropriate education and counseling
– Disintegration (feeling trapped in the role)

• Patient health status
– Medical decline and crisis (diabetes mellitus, COPD, CVA, Ca)
– Declining functional status (poor ADLs)
– Neuropsychiatric symptoms, wandering, agitation/aggression, delusions, insomnia, lack of appetite and unsteady gait
– Prior nursing home stay

Agenda of working with family member of the caregiver:
• How to explain placement to patients and caregivers
• Discussion of risk/benefits
• Community resources (education)
• Levels of care (nursing home and ALU)
• Nursing home and ALU selection
• Methods of payments
• Legal issues
• Patients’ (residents’) rights
• Adjusting to placement
• Advances directives and hospice care
• Life after placement
• Share experiences (face-to-face and support groups)

• Guilt: I did something wrong
• Placement is not “wrong”
• It takes a lot of courage
• We change the guilt for regret …
• And then, with all these emotions comes grief, the loss of the person who was, the loss of what we vowed to do for a loved one, the loss of our role.
• As one family member/caregiver said, “Healing comes from allowing ourselves to feel the loss, experience the sadness and honor our decision.”

Nestor H. Praderio, M.D., and Face to Face, LLC are dedicated to helping people live with Alzheimer’s through education, resources and local community events for caregivers and families in the Coastal Bend. For more information, call 361-238-7777, email, visit us online at or follow us on



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