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As America ages, it goes without saying that the assisted living business will be blooming for years to come. It’s no wonder we see new facilities popping up all around us – most of them doing quite well. Investment groups and private owners are buying existing homes, building out new locations, and/or expanding the facilities they already have – all to meet the ever-growing demand. There is a lot to know about this business model. Buying an existing REFE, and expecting a guaranteed profit is a lot harder than it looks, but if you are smart and buy right it can be a wise investment. In this article, we will look at many of the questions you should be asking yourself and your advisors during the evaluation process of purchasing an existing RCFE.

Indeed, there are many trips and traps when buying an RCFE (residential care facility for the elderly). And, of course, we all know that not all RCFE’s are created equal. Still, you have to ask yourself; where do I start, what should I be looking for, and what are the major red flags? Suffice it to say, there are many factors you must take seriously as well as a number of pitfalls – and, yes, as they say; “the devil is in the details,” and when it comes to purchasing an RCFE, Board and Care Facility, or Assisted Living Home you’ll need guidance and a solid strategy. First things first – you need to know what you are looking for.

What Size and Type of RCFE Would You Like to Purchase?

 Let’s get the terms straight, so we are all on the same page here. What are the differences between a RCFE, Assisted Living Home, Rest Home, and Board and Care Facility? Essentially, they are the same, at least as far as the State of California is concerned when it comes to licensing. All of these facilities must have the RCFE License to operate legally.

Out in the real world, most RCFEs are smaller with under 15-beds, and most are privately owned, often with the owners living in the local community. The larger Assisted Living facilities generally have corporate and investment company owners. These facilities are easily recognizable and usually come with private apartments (rooms) and different resident packages.

Licensed RCFEs can provide non-medical assistance such as eating, incontinence, dressing, personal hygiene, walking, supervision, and reminding and distributing a resident’s personal medicines as the prescription designates (self-administered). These facilities are not required to have doctors or certified nurses on their staff.

Consider why is the Owner Selling Their Facility in the First Place?

If Residential Care Facilities for the Elderly are such a good business model, then why on Earth is the owner selling? Do they have multiple facilities and want to sell their dogs, while keeping their flagship or profitable operations? Are the owners retiring themselves and don’t have heirs to take over the business, thus, just want to cash out? Is the facility rundown? Maybe owners don’t wish to invest in needed upgrades. Is the facility borderline and worried about licensing requirements and future inspections? Has the RCFE ever been licensed?

Has the facility been cited before for lapses in their mandatory compliance, is it at risk of license revocation? Have the owners been called into formal administrative hearings for non-compliance? Title 22 regulations are serious business, is the facility in chronic violation? How does the facility handle its compliance obligations and record-keeping, it’s easy to get into the ‘digital record-keeping doghouse’ in CA, a place no RCFE wants to be. Does the facility have a good reputation with the DSS – Department of Social Services? It’s a lot of questions, but these are all good things to know before you start making any offers.

It’s also important to look at the current residents and staff and their living/work conditions. Does the facility look clean? If you were a state inspector would you pass it for health and safety? What do their records show from previous inspections? Has the facility been paying the staff properly and recording overtime in a legitimate fashion? Are all members of the staff legal US citizens or have work VISAs? Again, if everything is on the up-and-up, try and gain an understanding as to why the owner is parting ways with their investment and make sure that they are not trying to pass on their pitfall to a new unsuspecting owner.

Remember: You are Buying a Business, Not Just Real Estate

Yes, while it is true that real estate can be a good investment over time and a hedge against future inflation, buying an RCFE is more about buying a business. The real estate should be a secondary consideration. In fact, if you separate out the two, and look at the real estate as one investment and the business as the other, you’ll have a clearer picture. Can the real estate stand on its own merit as a viable investment; long-term hold, or fix and flip? Can you afford to buy and hold the real estate if the RCFE doesn’t make a profit on its own?

How will you pay for it all if you lose the residents due to the change in ownership? There will be some attrition when new owners take over, the average is 20-30% – can you deal with that, at a time when you are planning to spend on new upgrades? What is your plan, do you have what you need to execute it? What if all the residents move out? Will the sellers consider a ‘clawback’ clause in the purchase agreement in the case that happens? Will the current owners stay on board for a while ensuring a smooth transition? Are the current owners a problem, perhaps you don’t want them anywhere near the facility?

How is the neighborhood? Are the surrounding neighbors happy with the facility? Have there been issues? Will they turn-out and speak against your future plans of expansion, upgrades or filings at the local planning commission as you try to get your construction or remodeling projects approved? Is the Neighborhood itself run down, will this prevent you from attracting residents or prevent you from commanding a fair and reasonable market price for those who come to stay?

Is the RCFE Profitable?

It is also important to evaluate if the facility is currently financially stable.  Consider if most of the residents are SSI residents. If so, keep in mind you will never be able to evict them, nor will you be able to raise prices much. If the facility isn’t making money now or barely scraping by, what will do when it is time to make repairs, upgrades, or comply with future regulations?

Will you need to expand the facility to improve revenue? Will you be able to renovate and add-on to the facility? Can you potentially do this out of cash flow? Speaking of cash flow, how timely are the residents with their payments? Are loved ones footing the bill, are they perpetually late with payments? Have the current facility owners been letting these late pays slide in the past? Are all the residents paying similar rates or have long-term ‘sweetheart deals’ been made for a few? Are all payments being made above board or are some residents paying ‘cash’ in off the books payments – if so this can cause havoc with proving revenue and financing your purchase.

How much work are the owners doing – do they have family members doing work, are they paid like regular employees? How is all this accounted for? Will your costs change drastically once you take over the business, as you will have to hire more staff than is currently servicing residents to offer the same level of care?

If you plan on doing substantial upgrades to the facility; what are the local building codes like, what restrictions are there on these types of facilities and what is the zoning in that specific area of the city? As you can see, most California cities have rules and building codes for Residential Care Facilities for the Elderly.

What other competition is in the area? Are new larger corporate Assisted Living Homes opening nearby with low-introductory offers? That is to say; can you compete with the ‘big boys’, the well-financed REITs with huge new facilities, an array of amenities, economies of scale, paid referral recruitment programs, and choice locations? You probably can if the business is profitable now, in full compliance, and/or you have a solid strategic plan.

Are the RCFE’s Facilities Well Maintained?

Title 22 is pretty specific when it comes to licensing of Residential Care Facilities for the Elderly (RCFE) and in 22 CCR 87303 “Physical Environment and Accommodations” it lays out the requirements for Maintenance and Operations of RCFEs. Inspections come every two years and if you aren’t in compliance, you will have a huge headache on your hands. The last thing a facility wants is to be considered ‘problematic’ by an inspector, the word gets around fast and it quickly snowball out of control. When purchasing an Assisted Living Home, Board and Care Facility, or RCFE you should look over the facility with a keen eye for detail as if you were a Title 22 Social Services Inspector. Looking through that lens, what do you see? Remember once you purchase the facility any of those problems you see will instantly become yours.

Can I Just Buy a Home and Turn It into an RCFE?

Yes, this is another option. Starting a new RCFE will require licensing, and more time to get up and running. You’ll need a comprehensive business plan and an expert consultant who has been through this process before, someone who knows the curves of the road ahead. You will need more working capital to start, but you won’t have to pay for ‘goodwill’ or a multiple of the annual gross revenue as you would if you were buying an existing RCFE. You will need to consider the costs and time associated with licensing, hiring, marketing, and training, and put into place a class-act compliance system. The biggest advantage is that you can build it out of your way with the most efficient and modern methodologies. Yes, it can be done. If you do it right, it might be the best option for you. Think on this, while shopping around and seeing what RCFEs are on the market.

Final Thoughts

We know that we have provided more questions than answers in this article. This was by design. Embarking on a journey to purchase an RCFE is one filled with questions that need to be answered and sometimes the hardest part is knowing what the right questions to ask are. Hopefully, this article has given you some insight into that. And if you find that you still need further guidance and/or consulting you can always reach out to our expert team to help make sure you are headed in the best possible direction. Good luck and happy shopping!

Assisted Living Education is the leading provider of  RCFE license application services, classes, products and services for assisted living. Our teachers are industry professionals with years of experience, engaging, entertaining and highly informative.

As humans, we are all prone to error. Even in industries where a single mistake could mean life or death, errors are made. But just because “to err is human” does not make it right. In the case of our aging senior population, RCFE Administrators have a responsibility to the health and wellness of their residents, who in their final years have become wholly reliant on others to meet their needs.

If you already have an RCFE Administrator certificate — or are soon to earn one through an RCFE Administrator course — you are duty bound to provide all individuals in your care with a safe and welcoming environment compliant with all state and local regulations.

Here are numbers 1-5 of the ten biggest mistakes made by RCFE’s — mistakes that make it that much more difficult for you to fulfill your obligations as an administrator.

1.   Admitting inappropriate residents

In 2013, nearly 7,000 complaints were made to the National Ombudsman Reporting System (NORS) regarding resident on resident conflicts in care senior facilities. Admitting sexually inappropriate, offensive, or combative residents into your community is all but certain to cause headaches down the line, and will quickly lead to a hostile and uncomfortable environment for the others in your care.

Residents have a legal right to be free from verbal, sexual, physical, and mental abuse, and to be treated with dignity and respect. Admitting inappropriate residents and those who mistreat others creates an environment counter to those rights.

2.   Hiring the wrong employees

Your employees are the backbone of your RCFE. They’re the people you interact with everyday and the hands who care for each and every one of your residents. Without them, you would not have a facility. With the wrong ones, your home will suffer for it. The hiring process is a delicate one; rife with potential pitfalls.

Fire-drilling the process of building your team is not the way you will find competent, qualified, candidates who are not only passionate about their work, but also show up day in and day out, even when it’s challenging.

You want people who aren’t just there for a paycheck, but rather come to work every day intent on making the lives of your residents better. Bad attitudes, contemptuousness, and disregard for a resident’s well-being have no place in the care industry, let alone your RCFE.

3.   Not training their employees fully and correctly

None of us walk into work that first day completely prepared for the job we’ve set out to do. The moment you are, you’ve already moved up to the next position. The assumption that someone will be able to hit the ground running and do everything perfectly from day one, is nothing short of folly. Employees need training, always. Not only when they begin, but over time as well. Training keeps us fresh and on top of shifting best practices. Without it, employees won’t be able to do their jobs properly, and if something goes wrong, you’ll have no one to blame but yourself.

Remember, always document all training an employee has done — otherwise, it did not happen!

4.   Disrespecting the LPA

Licensing Program Analysts, or LPA’s,  are state workers whose responsibility is to manage the licensing, evaluation and investigation of RCFE’s. As employees of the Community Care Licensing Division, about 50% of their time is spent out in the field conducting site visits and inspections of care facilities. They play a vital role in making sure that every RCFE meets state standards and is living up to its mission of properly serving the needs of its residents. Disrespecting your local LPA will do you no favors with the state. They have the authority to issue citations and civil penalties should an RCFE be found to be negligent or deficient — as they should. Viewing him or her as the enemy will accomplish nothing. It is not you against them, but you both against the problem.

5.   Not befriending the Ombudsman

Just as it is important for you to get up know your local LPA, so should you befriend the Ombudsman. As advocates for the residents of assisted living facilities, the Ombudsman only wants the same things you do:  a happy, healthy, and safe resident! Since it’s difficult for an aging person to advocate for themselves, somebody must. Befriending your Ombudsman will only make the process of resolving conflicts within your RCFE easier.

6.   Failing to complete proper resident file documentation

Any time there is a resident incident, such as a fall, it must be documented. Just as incidents like the above need to be reported to the resident’s physician asap (see mistake #10), it’s imperative that these incidents also have a paper trail. Liability is a huge potential problem for any RCFE, so defensive documentation is the best way to keep ahead of any issues down the line. When properly completing resident file documentation, specificity, precision, and descriptive detail are all musts. An incomplete file is not only a possible hazard to your residents, but it’s a lawsuit and a regulatory issue waiting to happen.

7.   Failing to do annual medical assessments on residents with dementia

The seriousness of dementia has lead states to enact numerous laws regulating the facilities accepting individuals with the condition. Among those is a requirement that all RCFE’s perform annual assessments on their residents with dementia. Since changes to one’s condition and behavior are all but certain to impact their care plan or which medications they take (see #9 on this list), it’s imperative that these be noted in a timely manner by licensees. Furthermore, these changes, if severe enough, may require a resident to be moved elsewhere — not all Residential Care Facilities for the Elderly are equipped or licensed to care for people living with advanced dementia.

8.   Failing to complete proper employee file documentation

A thoroughly kept personnel file is necessary to protect an employer in the event of audits or lawsuits, or any other type of employee-employer disagreement. In the case of the later, turnover becomes a risk. If another employee witnessed the issue in question, there’s a chance they are no longer available to give their account, thus forcing an employer to rely only on the documentation available in a personnel file. If few details exist in writing, that leaves the events open to debate, which can make it more difficult for an Administrator to justify cause for termination.

For a personnel file to comply, it should include state mandated  documentation. The file should also include any coaching, known policy violations, resident complaints, any disciplinary actions taken, and whether or not they met their performance goals. This record doesn’t need to be negative alone. A personnel file also serves as a justification of raises and promotions. So any noted positives should be included as well — key contributions, rewards, special recognition, client compliments, etc.

9.   Inadequate resident care plans

The Nursing Home Reform Act of 1987 was enacted by the federal government with the intention of advancing the rights of nursing home residents. This came after a study in 1986 showing that people living in RCFE’s at the time were not being afforded proper health care or personal treatment. In response, new laws were established that required all nursing homes accepting Medicare to develop detailed care and treatment plans for each resident, and follow them. Additionally, all residents were given the right to review their personal plans and to be given advanced notification of any changes.

Failure to comply with these regulations will not only be interpreted as neglect by regulators and the courts but does nothing but endanger your residents. Care plans exist to prevent elder abuse, minimize the potential for medication mishaps, and reduce the risk of medical mistakes leading to serious injury or even death.

10. Failing to notify the physician of a resident change of condition

The law mandates that any change of condition in the resident, no matter how small, must be communicated to their physician. A change in an individual’s condition could mean the difference between life or death, and a lapse in communication could prevent a resident from receiving critical treatment. It’s imperative that everyone on your resident’s care team is in the loop as changes occur, and it’s doubly important that these changes are noted in writing. We’ve all heard of the game “Telephone”:  word of mouth is terribly unreliable, but words on a piece of paper are far less likely to be misunderstood. Written records reduce the risk that a serious change in condition will get mixed up in the shuffle.

There you have it. Those are the top 10 mistakes that Residential Care Facilities for the Elderly make. Mistakes like the above put your residents at risk and your facility in jeopardy. Luckily, all of them are easily preventable.

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Assisted Living Education is the premier provider of RCFE classes, licensing, products and services for assisted living. Our teachers are industry professionals with many years of experience that are engaging, entertaining and highly informative. They offer RCFE consulting services and share real RCFE experience that will help you be successful in this fast growing career industry.

Joyous as the winter season can be for some — with fresh blankets of snow, a warm hearth, and the love of family surrounding them — for others it can be a time of struggle. Not only do the holidays and cold months often counterintuitively bring some people down, perhaps in part the result of past psychological drama, but they can also trigger persistent depression.

The Holiday Blues and Seasonal Affective Disorder typically manifest in similar ways, but their origins and treatment are different. In our last post we discussed the symptoms of each condition, as well as why they might befall certain residents in your care.

As caregivers, we play an important role in an individual’s day to day life; our close relationships with those we look after allow us to notice changes in mood and behavior, and alert other members of the care team. Keeping everyone in the loop, especially the psychiatric professional who will provide the diagnosis and treatment, gives a resident the best shot at recovery.

Here are some of the ways we can help our senior residents when the black dog begins to growl.

Helping Residents With Holiday Depression

With proper planning and program design, it may be possible to shift a resident’s mood throughout the holidays, and prevent the Holiday Blues from taking hold in the first place.

Well before the holiday season or particular event arrives, try to make an extra effort to engage with those residents who may be at risk for experiencing a depressive episode. One simple way to start is with a conversation.

Have Meaningful Interactions With Your Residents

Regular, casual engagements with your residents can turn into lasting relationships, with positive benefits for the residents. These relationships can help toward stabilizing emotional highs and lows that may be experienced during particular times of year, like the holidays, where residents can tend to feel more isolated and lonely.

Initiating daily conversations with each and every resident may sound like a daunting and time-consuming task, but even keeping it short and sweet can brighten a resident’s day. It’s not necessary to have a long, sit-down conversation, but try to create an ongoing dialogue whenever you see your resident either in passing, during medications administration, therapy sessions, mealtimes, or other times you may have scheduled contact with them.

Not every individual will be responsive, for various reasons. They may be shy, have trust issues, or they may have a disorder or cognitive issue that makes it difficult for them to interact openly with you. These individuals may take some time to warm up to you, or you may need to change your approach. Gauge how the individual reacts to conversation; you may need to back off and take smaller steps for them to open up. You may be doing most of the talking at first, but over time, you might find it balances out to a more even exchange.

Begin inviting them to group activities or outings, but ever push a resident into something they’re. not interested in doing. Nonetheless, always let them know they’re welcome to join if they want. These relationships might take longer to develop, but for resident and caretakers alike, they can be truly meaningful.

Even for residents who have advanced dementia or Alzheimer’s, or other cognitive or verbal limitations, you making an effort to reach them can make all the difference. Singing to them, talking to them, or signing with them will help these individuals feel connected to other people. Their responses may be different, but pay close attention to their behaviors and body language for positive or negative feedback.

These are all important components of trust-building, which can help you with other times in the long-run. As a trusted staff member, the resident may look to you in times of difficulty or even non-compliance to remain calm or de-escalate a tense situation.

Involve Everyone in the Festivities

Most facilities decorate and have events correlating with the major holidays, which is a great start to creating a warm and festive environment. If possible, find out which holidays in particular your residents like to celebrate throughout the year, and make an effort to have those represented if they aren’t part of the mainstream/regular celebrations. Even decorating a common area or the hall near their room can help bring some cheer. If the resident(s) are able, they can help explain the traditions with which they’re familiar and share stories they recall from their past.

The winter holidays are also a great time of year to invite people from the community to interact with residents. Local religious organizations, youth musicians, choirs, a capella or other community groups, and even schools can come sing and/or engage with residents and bring light to their holiday experience.

If possible, outings to local community events, or even driving around looking at holiday lights in the neighborhood are great excursions as well — but if that’s not doable, reaching out to the community and requesting greeting cards for the residents is another simple way to bring your residents cheer.

Recuperation Time is Important

With all of the activities and bustle of the holiday season, down time or quiet time is crucial. Even if elderly residents are enjoying themselves with all of the festivities, it is a change from their daily routine, and may be more physically and emotionally demanding on them than expected. As we age, it can take us longer to recover from activities, especially those out of our norm, whether we realize it or not. Moreover, stress and exhaustion can depress one’s immune response, causing someone to be more susceptible to illness.

Switching things up by having partial or half-day activities with ‘regular’ days in between will allow for recovery, and help reduce the mental and physical tolls the holidays can put on elderly folks.

Treating Residents Suffering From Seasonal Affective Disorder

Many of us are familiar with the term Seasonal Affective Disorder (SAD), but may not fully understand its condition, or even that there are different kinds of SAD. While we mentioned that there is a type of spring/summer SAD, the depression varietal we’re discussing here is fall/winter — the physiological condition coming to bear in the cold months.

For the period that the resident is suffering from SAD symptoms, antidepressants can be helpful, especially if the condition’s pattern is known. If a patient has a history of SAD, the an antidepressant regimen can begin prior to the expected onset of either winter or summer SAD. By starting sooner, the medication will be more effective.

Light therapy has also proven beneficial for sufferers of fall/winter SAD, especially among seniors who dislike taking medications or whom are already on multiple medications. Light therapy is also helpful for elderly who are not as able to go outside for natural exposure to light.

For residents with executive cognitive functioning within normal range, Cognitive Behavioral Therapy (CBT) is another possible treatment as well. What works best for every patient is different, and treatment can sometimes take a while to gain a foothold. In fact, there can be a great deal of trial and error in finding the right cocktail of medications or therapies, depending on one’s personal preference and brain chemistry.

A Light Through the Fog

The resident’s attending or personal psychiatrist/psychologist can determine the best course of treatment, depending on the individual’s needs, cognitive capabilities, and severity of symptoms. Even if the resident is receiving specific treatment from their psychiatrist/psychologist, it is pertinent to keep all doctors, therapists, dieticians, and other caretakers abreast of any adjustments to the resident’s routines, medical or otherwise. This helps maintain consistency and effectiveness of the treatment and resident care.

For residents suffering from Holiday Depression or Seasonal Affective Disorder, it might be a while before they can find their way to the bright side of life again, but always remember:  with your care and compassion, you are their light through the fog.

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Assisted Living Education is the leading provider of RCFE certification classes, licensing, products and services for assisted living. Our teachers are industry professionals with many years of experience that are engaging, entertaining and highly informative.

This is the second part of a two-part article. If you have not read Part One yet, we recommend doing so first clicking here.

Bullying in nursing homes is already on the level of a national crisis; enough so that the topic warrants an article of its own. But for openly LGBTQ+ people, it’s even more insidious — and often violent.

A lawsuit submitted by Lambda Legal on behalf of Marsha Wetzel against her assisted living community, which failed to protect her on a systemic level, shows just how bad it can be. For 16 months, despite dozens of complaints to administrators, Wetzel — a 70-year-old lesbian woman — was subjected to cruelty and violence by her fellow residents. Homophobic slurs were commonplace, and she often found herself targeted by the same people.

One man, a former police officer named Bob, rammed her scooter with his walker “hard enough to tip her chair and knock her off the [wheelchair] ramp,” and in a later incident told her that her partner Judy “died to get away from [her].” The harassment from Bob was so frequent and severe, that she soon felt she had no choice but to eat alone in her room, do her laundry in the middle of the night, and avoid the floor he lived on.

Sometime later, Wetzel was attacked in the mailroom — hit over the head from behind by an unknown assailant. “She went back to her room and cried but did not report the injury to staff that day because she did not think they would believe her.”

The reason she thought that was because, as she learned after dozens of complaints, the administrators never did. She was spit on by residents, assaulted in the elevator, and told that she would burn in hell — and each time she complained she was either accused of lying or told not to worry about it.  Eventually, the staff began to retaliate against her themselves, falsely accusing her of smoking in her room (an evictable offense), making fun of her because no one visited her during the Holidays, and at one point slapping her across the face.

Marsha Wetzel’s experience is not unique. It’s something that the vast majority of LGBTQ+ older adults have had to deal with — if not presently, then throughout the past. Wrote Tara Bahrampour, “Older lesbian, gay, bisexual and transgender (LGBT) people, including those among the first to come out as a political and social force, are increasingly apprehensive about encountering discrimination as they grow older and more dependent on strangers for care.” (Washington Post)

This apprehension only highlights why it’s so vital for caregivers to approach these situations with understanding and belief; their fear doesn’t exist without reason.

Compared to their cisgender¹  and heterosexual counterparts, LGBTQ+ older adults are already at a much greater risk of physical and mental illness. So stark is this health disparity that it’s been identified as one of the greatest concerns in public health. Says Karen Fredriksen-Goldsen, who led the pioneering 2011 study, “The health disparities reflect the historical and social context of their lives, and the serious adversity they have encountered can jeopardize their health and willingness to seek services in old age.”

In fact, 80% of respondents indicated that they’d been victimized “at least once in their lifetimes,” and nearly 40% had considered suicide at some point.

On top of the above health concerns and decreased care-seeking, LGBTQ+ seniors also have to contend with the following challenges that their peers do not:

• Increased social isolation and loneliness
• Decreased social support (less likely to be married or have children)
• Greater rates of poverty (often due to a difficulty in finding employment)
• Poorer nutrition
• Increased likeliness to smoke and binge-drink
• Higher rates of depression and anxiety
• For older lesbians and bisexual women, an elevated risk of cardiovascular disease and obesity, and a decreased likelihood of having a mammogram
• Higher rates of chronic conditions (including low back pain, neck pain, and a weakened immune system)
• Heightened rates of stroke, heart attack, asthma, and arthritis
• Premature mortality

Much of these differences were not known until recent years, which only serves as a reminder that there’s a need to develop prevention and intervention strategies so that lesbian, gay, bisexual, transgender, and queer-identified seniors and baby boomers can receive the healthcare and compassion they deserve.

In the coming years, you will find more and more LGBTQ+ elders in your care. Their differing needs, and also the need to be seen on a human level — with empathy, kindness, and an inclusion — means that we must build a foundation of understanding within the assisted living community. Across the country, facilities have begun to take note. Seminars are being held with residents and staff to reduce the rampant bullying taking place within their walls, and educational courses are available to teach nurse and caregivers how to interact with a community of seniors who have, for too long, remained invisible. At Assisted Living Education, we offer LGBT training and we are more than ready to shine a light on all the ways we can help make their lives better.  Please share with us your experience and feedback.

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Assisted Living Education is the leading provider of RCFE certification classes, licensing, products and services for assisted living. Our teachers are industry professionals with many years of experience that are engaging, entertaining and highly informative.

It’s been a scorching past couple of months. Across the U.S. and the world, temperature records dropped like flies this summer. Notoriously rainy London saw its picturesque green spaces burned to an unsightly, ocre crisp, with the rolling estates of Hampstead Heath looking more like a high summer’s African savannah. As people across the planet continue to experience heat waves and droughts the likes of which they’ve never felt, they’re finding themselves at a greater risk of dehydration than ever before.

In seniors, this is especially dangerous. The trouble is that with it’s oddball constellation of symptoms dehydration can sometimes be tricky to diagnose. Our body becomes less efficient as we age; things it did with ease when we were young—like hold on to water, or not make us groan when standing up—become challenging.

For a species comprised of at least half H2O (the percentage drops as we grow older, from about 70% to 50% over time), this is less than ideal. So with that in mind, considering dehydration is in fact a year-round risk for seniors, we wanted to take a look at how this serious condition can affect our aging population, and what can do to diagnose, treat, and prevent it.

Dehydration Risk Factors

As we age, we lose our ability to perceive thirst as keenly as when we were young. For the seniors in your care, this natural state means that they are less likely to consume as much liquid as they need to stay healthy. This quickly puts an individual who is already low on body water at an even greater risk of dehydration.

One study, which looked at elderly patients as they were admitted to the hospital, showed that 37% were dehydrated upon arrival. Additional research suggests that one in five older individuals living in assisted care does not drink enough fluids.

For individuals with Alzheimer’s or other forms of dementia, who may not remember to ask care staff for a glass of water, this risk is even greater:  they’re six times more likely to be dehydrated. This is especially problematic considering that even mild dehydration can exacerbate their cognitive symptoms, leading to increased confusion and worsened thinking skills.

In some cases, seniors may be reluctant to drink fluids out of fear of incontinence and the embarrassment that can come with it. Anxieties about toilet issues are very common among the residents of care homes, but it’s a worry that often goes unnoticed in care homes, because individuals are unlikely to want to discuss it.

And yet, studies actually show a positive relationship between proper hydration and a decrease in anxiety levels among the elderly. This might not correlate for individuals with continence anxiety, but it’s something to keep in mind when searching for ways to improve the mental health of residents.

Other factors that contribute to dehydration include mobility issues, medications (aka “water pills,” with diuretic properties) used to treat high blood pressure, acute illnesses (vomiting, fever, diarrhea, and infection all contribute to water loss), being a resident of an assisted living facility (where access to fluids is largely dependent on the availability and attentiveness of caregivers), and difficulty swallowing.

Diagnosing Dehydration

Dehydration can be very difficult to diagnose. The symptoms it presents with are all easily attributable to other conditions, and they may not always present in a clear cut way, so symptoms on their own are not a reliable basis for a diagnosis.

Some of the most common symptoms, and the ones that people are told to look out most with dehydration, include:

• Extreme thirst
• Decreased frequency of urination
• Dark-colored urine
• Fatigue
• Dizziness
• Confusion and delirium (either new, or worse than usual)
• Racing heart (typically a rate exceeding 100 bpm)
• Low systolic blood pressure
• Sunken eyes

Rather than simply basing a dehydration diagnosis on symptoms, it makes more sense to keep on eye out for these, and then follow up with a more reliable test.

For older adults, a laboratory blood test is the most accurate method of diagnosing dehydration. Studies have shown that routine tests done by care homes to spot signs of dehydration (such as pinching the skin on the back of the hand, or performing a urine dipstick test) are also unreliable.

Prevention of Dehydration

Of course, the best method of treating dehydration among seniors is to prevent it from happening in the first place. With this in mind, there are a number of steps that a caregiver or nursing staff can take to ensure an individual receives enough fluids.

Here are just a few:

• Make fluids available throughout the day, and on a schedule.
• Since older adults might be reluctant to drink a large glass of water in one sitting (see:  continence issues), consider offering smaller quantities of fluid more frequently.
• Provide a beverage that the individual in your care enjoys.
• Ask whether they prefer to drink through a straw (this might be easier, mobility-wise, than having to lift a cup to their mouth)
• Keep a urination log, and a log of their fluid intake, and note when instances of incontinence occur. Check in with your resident about whether toilet issues are a reason why they are reluctant to drink.
• Consider placing the older individual on a bathroom schedule. This might be especially appropriate for someone with memory troubles or mobility issues.

Dehydration is a serious condition, and if left unchecked can lead to kidney failure and death. While mild dehydration is usually easily treatable by merely increasing fluid intake and electrolytes, the worst cases call for a trip to the emergency room for intravenous fluids, or even dialysis and other kidney-supporting methods.

Hospital visits are scary, no matter the reason, and they put an enormous amount of stress on an individual and their family. Making sure the older person in your care is properly hydrated is one of the simplest ways to ensure their health and happiness, and will go a long way toward improving their quality of life.

If you or anyone under your care is exhibiting symptoms of dehydration, or any other worrisome symptom, please be sure to contact a licensed medical provider for further assistance.

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