Assisted Living Residents Research Articles

A Randomized Control Trial of the Application of Efficacy Training to Balance Assessment

Reduced balance confidence often translates into a fear of falling, which reinforces a sedentary lifestyle.Purpose: A self-efficacy intervention was assessed for improvements in balance confidence and performance when compared with controls.Methods: Thirty-five assisted-living residents were randomly assigned to an exercise-only or exercises and efficacy-training groups two times every week for four weeks. Results: Activities of Balance Confidence Scale (ABC) using ANCOVA demonstrated no significant differences (F = 0.005, p = 0.944) in balance confidence. Balance performance however, as measured by the Berg Balance Scale using ANCOVA was significantly improved (F = 33.453, p = 0.0001).Conclusion: This intervention produced significant changes in balance performance without demonstrating significant changes in confidence measurement. Continued assessments and intervention trials such as this will demonstrate scientific evidence needed to promote optimal functioning in older adults.

Depression in Assisted Living Is Common and Related to Physical Burden

The objective of this study was to obtain a direct estimate of the prevalence of depression, its associated factors, and rates of treatment among residents of assisted living (AL) facilities in central Maryland. One hundred ninety-six AL residents were recruited from 22 (10 large and 12 small) randomly selected AL facilities in the city of Baltimore and seven Maryland counties. Chart review, staff and family history, comprehensive in-person resident evaluation, and the Cornell Scale for Depression in Dementia (CSDD) were administered by an experienced team of geriatric psychiatry clinicians. Those scoring >7 on the CSDD, a cut point repeatedly associated with poor outcomes, were considered clinically depressed. Participants had an average age of 86 years, most were female and widowed, and 68% met consensus criteria for dementia. Twenty-four percent (47 of 196) of the sample was depressed. In bivariate analyses, depression was significantly related to medical comorbidity, need for activities of daily living (ADLs) assistance, more days spent in bed, and less participation in organized activities. After controlling for pertinent covariates in a regression model, only need for ADL assistance remained significantly associated with depression. Forty-three percent of those currently depressed were receiving antidepressants and were more likely to receive them if they lived in a large AL facility. Sixty percent of depressed residents had no regular source of psychiatric care. In the first clinical study implemented by geriatric psychiatry professionals in AL, depression was found to be common, undertreated, and related to physical burden. AL is a rapidly growing segment of long-term care and represents an important setting in which to find and treat serious depression.

Examining the Physician’s Role With Assisted Living Residents

In response to the rapid growth of the assisted living (AL) residents, this article considers the resulting range of roles, opportunities, and challenges physicians may face as increasing numbers of their older adult patients choose residence in AL facilities. The problem is framed by providing an overview of the AL industry and reviewing AL resident demographics and health status characteristics. The discussion section examines the pervasive involvement of physicians with AL residents, reviews professional position statements on health care in AL, and reviews the emerging AL-focused clinical literature. In conclusion, the paper proposes key elements of a research agenda including establishing baseline physician-AL activity levels, physician collaboration with mid-level practitioners, and exploring physician involvement in chronic care and health promotion in AL.

A Randomized Control Trial of the Application of Efficacy Training to Balance Assessment

Reduced balance confidence often translates into a fear of falling, which reinforces a sedentary lifestyle.Purpose: A self-efficacy intervention was assessed for improvements in balance confidence and performance when compared with controls.Methods: Thirty-five assisted-living residents were randomly assigned to an exercise-only or exercises and efficacy-training groups two times every week for four weeks. Results: Activities of Balance Confidence Scale (ABC) using ANCOVA demonstrated no significant differences (F = 0.005, p = 0.944) in balance confidence. Balance performance however, as measured by the Berg Balance Scale using ANCOVA was significantly improved (F = 33.453, p = 0.0001).Conclusion: This intervention produced significant changes in balance performance without demonstrating significant changes in confidence measurement. Continued assessments and intervention trials such as this will demonstrate scientific evidence needed to promote optimal functioning in older adults.

Sleep disturbances in the elderly residing in assisted living: findings from the Maryland Assisted Living Study

A majority of the elderly suffer from some sort of sleep disturbance. Common sleep disturbances are insomnia and excessive daytime sleepiness. There are no published studies on the prevalence of sleep disturbance in the assisted living (AL) setting. To estimate the prevalence, types, and associations of sleep disturbance in a stratified random sample of AL residents, and to explore the effect of sleep disturbance on cognitive and physical functioning, as assessed by the Mini- Mental State Exam (MMSE) and the Psychogeriatric Dependency Rating Scale (PGDRS). Participants were 198 randomly selected assisted living residents in 22 Maryland facilities. Participants were rated on an 11-item sleep questionnaire regarding insomnia and daytime sleepiness. Sleep disturbance was present in 69% of residents, insomnia (IN) in 42% and excessive daytime sleepiness (DS) in 34.6%. IN and DS scores were not significantly correlated(r = 0.10, p = 0.19). Use of hypnotics, sedating antidepressants, and depression were associated with insomnia. Depression and poor general medical health were associated with daytime sleepiness. On a cognitive task (Mini Mental State Examination) participants with insomnia only out-performed participants with no sleep disturbance and daytime sleepiness; on a measure of physical function (PsychoGeriatric Dependency Rating Scale- physical domain), participants with insomnia fared better than those with daytime sleepiness only and those with both insomnia and daytime sleepiness. Participants with DS only performed worse on both measures compared to those with no sleep disturbance, those with insomnia only, and those with both insomnia and daytime sleepiness. The prevalence of sleep disturbance in AL is similar to that reported in nursing homes. Daytime sleepiness is associated with poorer cognitive and day-to-day functioning, while insomnia is associated with better outcomes. Effective management of DS may lead to improved functioning in the AL residents.

Medicare expenditures for residents in assisted living: data from a national study.

To provide preliminary data on Medicare expenditures for assisted living facility (ALF) residents and to investigate whether ALF characteristics were related to Medicare expenditures for ALF residents. Data from the National Study of Assisted Living for the Frail Elderly conducted in 1998-1999. This analysis was restricted to the 40 percent of ALFs in that sample that adhered to the assisted living (AL) philosophy by offering more than minimal levels of services and privacy. This study involved the approximately 1,200 residents who remained in an ALF from baseline to follow-up data collection. Six months of postbaseline Medicare claims were acquired for 545 of these residents, who did not differ significantly from the larger sample. Baseline individual and facility data were collected in personal interviews with residents and a combination of personal and telephone interviews with facility staff. Medicare claims data were acquired from the Centers for Medicare and Medicaid Services. Cross-sectional analyses using logistic and ordinary least squares regression techniques were used to determine the relationships among individual and facility characteristics and Medicare utilization and expenditures. On an annualized basis, AL residents incurred Medicare costs of approximately US dollars 4,800. Just less than 15 percent of AL residents accounted for over 75 percent of total Medicare costs. Both the likelihood of utilizing Medicare-covered services and the intensity of service use were largely unaffected by the characteristics of the ALF in which residents lived. Utilization was largely a function of individual characteristics. The only exception to this general finding was that those individuals who utilized services and resided in smaller ALFs had significantly lower average expenditures than did individuals in larger ALFs. These preliminary data imply that both the level and distribution of Medicare expenditures among ALF residents were similar to those among the general community-dwelling Medicare beneficiary population. No significant relationships were observed between ALF characteristics and Medicare expenditures, except the effect of facility size. This result may imply that how the AL industry eventually defines itself in terms of services and amenities, other than size, may have little impact on Medicare expenditures for ALF residents. However, this is a single, initial study, so caution must be exercised when considering the implications of these results.

Medicare Expenditures for Residents in Assisted Living: Data from a National Study

Objective. To provide preliminary data on Medicare expenditures for assisted living facility (ALF) residents and to investigate whether ALF characteristics were related to Medicare expenditures for ALF residents.Data Sources/Study Setting. Data from the National Study of Assisted Living for the Frail Elderly conducted in 1998–1999. This analysis was restricted to the 40 percent of ALFs in that sample that adhered to the assisted living (AL) philosophy by offering more than minimal levels of services and privacy. This study involved the approximately 1,200 residents who remained in an ALF from baseline to follow‐up data collection. Six months of postbaseline Medicare claims were acquired for 545 of these residents, who did not differ significantly from the larger sample.Data Collection. Baseline individual and facility data were collected in personal interviews with residents and a combination of personal and telephone interviews with facility staff. Medicare claims data were acquired from the Centers for Medicare and Medicaid Services.Study Design. Cross‐sectional analyses using logistic and ordinary least squares regression techniques were used to determine the relationships among individual and facility characteristics and Medicare utilization and expenditures.Principal Findings. On an annualized basis, AL residents incurred Medicare costs of approximately $4,800. Just less than 15 percent of AL residents accounted for over 75 percent of total Medicare costs. Both the likelihood of utilizing Medicare‐covered services and the intensity of service use were largely unaffected by the characteristics of the ALF in which residents lived. Utilization was largely a function of individual characteristics. The only exception to this general finding was that those individuals who utilized services and resided in smaller ALFs had significantly lower average expenditures than did individuals in larger ALFs.Conclusions. These preliminary data imply that both the level and distribution of Medicare expenditures among ALF residents were similar to those among the general community‐dwelling Medicare beneficiary population. No significant relationships were observed between ALF characteristics and Medicare expenditures, except the effect of facility size. This result may imply that how the AL industry eventually defines itself in terms of services and amenities, other than size, may have little impact on Medicare expenditures for ALF residents. However, this is a single, initial study, so caution must be exercised when considering the implications of these results.

Physician care in assisted living: A qualitative study

To identify patterns and emerging concepts used by assisted living (AL) residents, their families, and the facility staff to describe the care provided by physicians to the AL residents. Qualitative research and analysis based on audio-taped and transcribed ethnographic interviews with residents, family members, and staff of AL facilities. Three AL facilities representing small and traditional AL facilities. Forty-three in-depth interviews including 16 AL residents, 13 family members, three facility managers, and 11 staff members. Ethnographic, audio-taped interviews coded by consensus by a doctoral-level analysis team. Coding focused broadly on any references to physicians or doctors in the interviews. Emergent themes included four major physician-related themes in AL including: magnification of physician authority; disagreements with physician care; physician communication; and continuity/discontinuity of physician care. Physicians caring for residents of AL facilities should consider how residents, families, and staff stakeholders may influence their patient care for AL residents in terms of their authority, decision-making, communication, and continuity of care.

Independence in assisted living

The aims of this study were to understand the meaning of independence for residents of assisted living and to identify factors influencing the operationalization of independence in this setting. Qualitative interviews were conducted with 17 providers and 55 residents in 17 assisted-living facilities in Georgia. Data were analyzed by using the grounded theory method. Findings show that assisted-living residents retained a strong value for independence and that independence had multiple dimensions of meaning. Whereas independence in most cases was reduced to performing everyday activities of daily living (ADLs), the multidimensional nature of meaning allowed residents with significant disability both to continue to perceive themselves as independent and to find satisfaction in their remaining abilities. Resident self-care requires significant effort from both residents and providers, but it also has far-reaching potential to help residents maintain intact identities and may hold the key to extending their stay in the assisted-living facility (ALF) environment.

The Maryland Assisted Living Study: prevalence, recognition, and treatment of dementia and other psychiatric disorders in the assisted living population of central Maryland.

To obtain a direct estimate of the prevalence of dementia and other psychiatric disorders in residents of assisted living (AL) in Central Maryland, and their rates of recognition and treatment. Comprehensive review of history and cognitive and neuropsychiatric evaluations using widely accepted instruments in a randomized cohort of AL residents, stratified by facility size. An expert multidisciplinary consensus panel determined diagnoses and appropriateness of treatment. Twenty-two (10 large and 12 small) randomly selected AL facilities in the city of Baltimore and seven Maryland counties. One hundred ninety-eight volunteers who were residents of AL, 75% were aged 80 and older, and 78% were female. Potential participants were randomly chosen by room number. There was a 67% participation rate. Overall rate of dementia, noncognitive active psychiatric disorders, and recognition and adequate treatment of dementia and psychiatric disorders, as determined by consensus panel. Two-thirds (67.7%) of participants had dementia diagnosable according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (81% small facilities and 63% large). Family or caregivers recognized 78% to 80% of dementias. Seventy-three percent of dementias were adequately evaluated, and 52% were adequately treated. Of the 26.3% of participants who had an active noncognitive psychiatric disorder, 58% to 61% were recognized and 52% adequately treated. Dementia and psychiatric disorders are common in AL and have suboptimal rates of recognition and treatment. This may contribute to morbidity and interfere with the ability of residents to age in place.

Assisted living: aging in place and palliative care.

Principles of upstream palliative care can guide the planning, programs, and services associated with aging in place in assisted living residences (ALRs). Frail older adults who do not need a nursing home level of care are choosing to live-and die-in ALRs. This article describes the context of assisted living, resident characteristics, key indicators of palliative care, barriers to end-of-life care, and the role, responsibilities, and potential for professional nursing in assisted living. Stakeholder concerns about staff knowledge and skills in care of the elderly, medication management, the risks associated with residential care, and nursing delegation are discussed.

Comparing Health Status With Healthy Habits in Elderly Assisted-Living Residents

There is a growing number of older adults in America. Assisted-living facilities have become a more prevalent residence for this increasing population. In the study described in this article, a secondary data analysis was completed using residents of several LifeTrust America, Inc.,'s assisted-living facilities across the Southeastern United States. There were 1,079 residents who completed the Healthy Generation Survey. Residents were asked whether they currently, previously, or had never had certain health conditions. They also responded to various questions about their current participation in healthy habits, such as using cigarette or tobacco products, moderate alcohol consumption, eating breakfast, eating healthy snacks, getting 7-8 hours of sleep each night, drinking the daily recommended amount of water, and participating in regular physical exercise. The research question asked if there was a relationship between current healthy habits and physical health. The study found that individuals with more current physical health conditions also reported greater participation in healthy habits. This could lead to the conclusion that after individuals acquired certain physical health conditions, they began to participate in more healthy habits. Also of significance was the finding that participation in physical exercise and recreational activity related to greater participation in all other healthy habits.

Depression in Assisted Living: Results From a Four-State Study

Assisted living is a rapidly-growing sector of long-term care, but little research has been done on depression in this setting. Using data from a large sample of assisted-living residents, the authors sought to 1) describe the prevalence of depression and depressive symptoms; 2) identify resident characteristics associated with depression; and 3) examine the relationship between depression and the rate of nursing home placement and mortality. A group of 2,078 residents age 65 and older were enrolled from 193 assisted-living facilities across four states (Florida, Maryland, New Jersey, and North Carolina). Residents were classified as depressed if their score on the Cornell Scale for Depression in Dementia (CSDD) exceeded 7. Using this criterion, 13% were depressed, and only 18% of those were on antidepressants. Over one-third of residents had symptoms of depression, such as anxious expression, rumination, or worrying, and 25% displayed sad voice, sad expression, or tearfulness. Depression was significantly associated with medical comorbidity, social withdrawal, psychosis, agitation, and length of residence in the facility. Depressed residents were discharged to nursing homes at 1.5 times the rate of nondepressed residents. Rates of mortality were also higher for depressed residents, but only those with severe depression (CSDD >12) had a statistically significant increased rate of death. The mission of assisted living is to help older adults retain autonomy, privacy, and quality of life in a personalized environment. Greater effort should be made to detect and treat depression in this setting, both to reduce suffering and prolong the resident's ability to remain in their preferred environment.

The process of mediated aging-in-place: a theoretically and empirically based model

Aging-in-place is a complex geographical process mediated by institutions and other social forces. Two relatively under-studied services based on an aging-in-place strategy are adult day centers (ADCs) and assisted living residences (ALRs). This paper begins by re-casting aging-in-place as a process of place integration, based on a combination of geographical theory and John Dewey's philosophy of experience. Using empirical evidence from qualitative fieldwork and analysis of that evidence, the paper then introduces a theoretical model of the place integration process for older adults using ADCs and ALRs. The analysis describes how the domains of home and community are central to the originating problematic situation of these persons. It suggests that ‘socio-geographical differentiation of older adults’ situations’ is involved in these domain problems and describes how the process works to influence the core processes of place integration generated by the ADC or ALR setting. The analysis then explains three core processes of the model: ‘re-shaping the experiential context through space and place’, ‘creating meaning through place-centered activity’, and ‘contesting space and place’. The model also includes two final component processes. One is the distillate of the core processes, termed ‘approximating home and community’. The other is ‘instability as ongoing challenge’ to place integration. A brief conclusion discusses theoretical and policy implications drawn from the study.

Predictors of psychological well-being among assisted-living residents.

Assisted-living facilities are a rapidly growing source of supportive housing for frail elderly people. This study examined the psychological well-being of elderly assisted-living residents and factors associated with well-being. Participants were nondemented elderly residents of an assisted-living community in the urban southeast. Depression, life satisfaction, and demographic, health, and social support variables were measured through face-to-face interviews. A sizeable minority of the residents reported high levels of depressive symptoms and low life satisfaction. Female gender, self-reported health, functional impairment, perceived social support, and participation in activities were significantly associated with well-being. The predictive value of gender and health variables were reduced when social support was introduced. Implications for policy and social work practice are discussed.

Effects of Recumbent Stepper Exercise on Blood Pressure, Strength and Mobility in Residents of Assisted Living Communities: A Pilot Study

Objective: To examine the effects of a total body recumbent stepper exercise program on blood pressure, strength and walking speed in elderly, assisted-living residents.Design: A non-experimental (longitudinal) pre-post-test descriptive design was used to determine changes in physical performance measures after 13 weeks of recumbent stepper exercising.Setting: Morningside Assisted-Living Communities in Middle Tennessee.Participants: Thirty-nine volunteer, assisted-living residents with mean age of 85.5 ± 6.6 years, height of 1.6 ± .1 m, and weight of 63.6 ± 9.6 kg.Interventions: Recumbent Stepper exercise program. The residents were classified into two groups based on the total time of exercise logged over the test period. One group exercised less than an average of nine minutes per week while the other group averaged nine or more minutes of exercise per week.Main Outcomes Measures: The residents were tested on physical characteristics, sitting and standing blood pressure, mobility (15.2 meter timed walk), and six strength measurements on a hydraulic exercise machine.Results: Statistically significant differences pre- and post-intervention were found on several measures of blood pressure, strength, and mobility. While residents exercising less than nine minutes per week tended to remain stable or show changes in adverse directions on these measures (e.g., decreased Shoulder Press strength, p < .05), residents exercising at least nine minutes per week demonstrated positive improvements (e.g., Knee Flexion and Back Pulldown, p < .01), as well as increased mobility (p < .01). Statistically significant decreases were also found for measures of sitting and standing blood pressure (p < .05).Conclusions: The results of this study revealed that assisted-living residents who exercised on a recumbent stepper as little as nine minutes per week decreased blood pressure, and increased strength and walking speed. This effect holds true even in the oldest-old individuals.

Informal Help in the Assisted Living Setting: A 1‐Year Analysis*

Using statewide data from Oregon (N= 596 at baseline), this study compares informal help received by assisted living (AL) and nursing home (NH) residents over a 1‐year period. The analysis also identifies predictors of informal help among AL and NH residents with an expanded version of the Behavioral Model. Instrumental assistance (i.e., help with shopping, appointments, transportation) was more prevalent in the AL setting throughout the analysis. Regression models found multiple predictors of informal help among AL and NH residents (i.e., predisposing, enabling, and need characteristics). The results imply that the AL setting facilitates informal help provision; however, predictors of support are varied and require greater attention in future research.

An Interest Inventory of Games for Older Adults

Objectives. The objectives of the study were to (1) develop an interest inventory of games for use with older adults and (2) identify older adults' preferences for specific games.Method. Focus groups identified games popular among older adults, and those games comprised a preliminary interest inventory given to 92 respondents, aged 60-95. Respondents included well-elders living independently, assisted-living residents, adult daycare clients, and nursing home residents. Forty-eight games of interest to at least 5% of respondents comprise the final interest inventory.Results. Eleven games were of interest to at least one-third of all respondents, with dominoes, checkers, and bingo of interest to more than half. Well-elders slightly favored sedentary games to physically active games, while other groups greatly favored sedentary games. Well-elders demonstrated the greatest breadth of interest in games.Conclusion. Games are a purposeful activity that hold high interest for older adults and consequently have significant value as therapeutic tools for occupational therapists.

Characteristics and outcomes of dementia residents in an assisted living facility

Background Assisted living (AL) is the fastest growing segment of residential long-term care in the US. At least half of the estimated 1 million AL residents have dementia or cognitive impairment, with many AL facilities offering specialized dementia services. Little research has been done on the demographics, outcomes, or clinical variables of this population. Methods Participants were a cohort of 144 residents admitted to the AL unit of Copper Ridge, a specialized dementia-care facility. Comparison samples included 737 patients with dementia residing in other locations (home, nursing home, and other assisted living facilities). Selected measures of cognition, behavior, medical health, and function were taken at admission to AL and at 6-month intervals. Results When compared with residents of the dementia-specialized AL facility, dementia patients at home were younger, less cognitively impaired, and less likely to exhibit wandering, delusions, or aggression. Residents of a dementia-specialized nursing home had more cognitive impairment, greater medical comorbidity, and were more dependent on caregivers. The 2-year mortality rate in the dementia-specialized AL was 23%, significantly lower than rates reported for nursing homes. Primarily due to increasing care needs, most residents in the specialized AL relocated to a nursing home after a median stay of 10.9 months. Depression, falling, and wandering were significant predictors of the transition. Conclusion Dementia-specialized AL facilities occupy a unique position in the long-term care continuum that is distinct from home-care and nursing home facilities. This research is the first step toward understanding the significant dementia population residing in assisted living. Copyright © 2000 John Wiley & Sons, Ltd.

Characteristics and outcomes of dementia residents in an assisted living facility.

Assisted living (AL) is the fastest growing segment of residential long-term care in the US. At least half of the estimated 1 million AL residents have dementia or cognitive impairment, with many AL facilities offering specialized dementia services. Little research has been done on the demographics, outcomes, or clinical variables of this population. Participants were a cohort of 144 residents admitted to the AL unit of Copper Ridge, a specialized dementia-care facility. Comparison samples included 737 patients with dementia residing in other locations (home, nursing home, and other assisted living facilities). Selected measures of cognition, behavior, medical health, and function were taken at admission to AL and at 6-month intervals. When compared with residents of the dementia-specialized AL facility, dementia patients at home were younger, less cognitively impaired, and less likely to exhibit wandering, delusions, or aggression. Residents of a dementia-specialized nursing home had more cognitive impairment, greater medical comorbidity, and were more dependent on caregivers. The 2-year mortality rate in the dementia-specialized AL was 23%, significantly lower than rates reported for nursing homes. Primarily due to increasing care needs, most residents in the specialized AL relocated to a nursing home after a median stay of 10.9 months. Depression, falling, and wandering were significant predictors of the transition. Dementia-specialized AL facilities occupy a unique position in the long-term care continuum that is distinct from home-care and nursing home facilities. This research is the first step toward understanding the significant dementia population residing in assisted living.