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When my dad was pleasant but confused all was well.. then he went upside done in a really short time.. up all night, got nasty and violent. We have no sleep once for 36 hours, and he was angry the whole time. That was when we knew we needed a break
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This depends on the primary caregiver and the resources available at home, as well as the patient's status. When the needs exceed the resources and/or skills available, then it is time for placement.

If the live long enough, persons with dementia generally reach a point where they need three shifts of rested, alert, and skilled caregivers available. If you can afford to provide this, the option to keep the loved one at home is possible.

If the loved one needs care requiring skill, strength, stamina, etc not available in the household, then placement is a strong option. For example if the loved one needs help transferring and the caregiver is not strong enough to provide it, some kind of equipment might be considered in the home, or going to a care center might provide solutions to other challenges as well.

It really is more about what the caregiver can handle (or hire) in the home.

The stimulation of interaction with other adults, a standard and predictable routine, and supervision can actually be beneficial for the patient, so it shouldn't be thought of as a "last resort to be avoided at all costs." Don't put it off so long that the caregiver suffers damaged health.
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Some families reach this point fairly early on and others manage to hold out until the very end. It's a really personal decision, but generally if they need more care then you are willing or able to give at home and/or it is affecting the caregiver's health and safety it is time to consider a facility.
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The doctor(s) do the referrals, and sign the paperwork. Ask them. There are a lot of threads in this website, by the way, that deal with this difficult step in your life, and in the life of your loved one.
There is a search site box, upper right hand corner below My Account, and you can search this site, get a lot of answers, besides the "live ones" that will pour in.

Stay strong, you are helping, not harming by making this move.

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