Five selected criteria seem to be indispensable for truly specialized units for the care of Alzheimer patients.

1. A highly selected population of residents. They may suffer from Alzheimer disease, vascular dementia or other degenerative dementias. In acute care units, patients who present only cognitive impairment may be admitted for brief evaluation. Specialized long-stay units generally admit patients with severe dementia associated with behavioural problems. Recent studies have shown that 68 to 85% of patients in special care units had severe dementia and 65% had serious communication difficulties. However, we should remember that about 80% of residents of conventional nursing homes have cognitive impairment which often still goes unassessed.

2. A specially designed architectural environment. This should help to prevent fugues and accidents as well as making the surroundings as comfortable as possible for the patient, his or her family and the care staff. The colour scheme is particularly important (proper use of colour can have a tranquillizing effect and can also be used to help patients to find their way around), as is adequate lighting and insulation against noise in order to create as calm an environment as possible. If there is a garden where patients can go out, this will help to maintain physical activity and quality of life in satisfactory conditions of safety.

3. Trained, experienced, specialist staff. Properly trained staff are essential to special care units. They are no longer subjected to Alzheimer disease, but are better equipped to contend against it, and know how to attenuate the situations which make the patient aggressive. They will also be able to deal with problems at mealtimes or with the patient’s aggressiveness when being washed or bathed. With training, the staff can pass on their knowledge to the family, reassure them and give them advice to help with everyday living. This is one of the most important aspects of special care units. Recent studies have shown that staff turnover is lower in special care units than in conventional units caring for elderly persons. Staff training in the use of scales evaluating autonomy in the activities of daily living (ADL, IADL), those assessing feeding problems (Blandford scale), behavioural problems (NPI, Cohen-Mansfield) or burden on caregivers (Zarit scale), is of particular value not only in improving patient care but also in increasing job satisfaction.

4. Family participation. Alzheimer disease involves the whole family. It affects the mental and physical health of the patient’s immediate relatives. It is essential for families to receive support and information. Educational sessions for families are therefore organized in Alzheimer care units. Their content differs in short stay units when the diagnosis is announced, or when complications develop. But even in long-stay units, families should be able to continue to take part in the life of the institution and in patient care, in particular mealtimes, physical activity and organized activities.

5. A specific care project. Special care units must have a specific care project aiming to optimize the quality of life of the patients and their relatives. The first problem which arises is that of breaking the diagnosis to the patients or the family in the early stages of the disease. Then comes the follow-up of the patient in order to detect and manage complications as rapidly as possible (weight loss, gait abnormalities, psychiatric problems) as well as intercurrent disorders. A programme of activities must also be organized for residents in long-stay units. Such activities have been shown to decrease significantly the behavioural problems and sleep disturbances so often observed. Maintaining quality of life and terminal care are the most difficult aspects of medical care of patients with Alzheimer disease. Recent studies have demonstrated the lack of efficacy and the burden of artificial feeding in these patients. Similarly, treatment of pneumopathies in bedridden patients with terminal dementia should be debated.