Residential Care/assisted Living Research Articles

Two lives in transition: Agency and context for assisted living residents

This research uses data on two “focal case” individuals residing in one residential care/assisted living (RC/AL) facility, collected as part of a larger ethnographic study exploring later-life transitions, including those leading to the moves into housing and care settings. In-depth examination of the 10-year transition histories of these two women highlights the major erosion of autonomy with advancing frailty, illness, and relocation into supportive housing. A second major theme is that an understanding of the contemporary events and challenges for these two individuals is substantially enhanced by nesting them within the temporal context of earlier life events, including personal relationships, social events, and preferences. Individual history, elicited from resident, family, staff and professional views, serves to contextualize current choices and reactions to key events. As researchers, adding this temporal context moves our understanding of their identities well beyond a simplistic snapshot view as “resident” in AL.

Is Hospice Associated with Improved End‐of‐Life Care in Nursing Homes and Assisted Living Facilities?

To examine whether hospice enrollment for nursing home (NH) and residential care/assisted living (RC/AL) residents near the end of life is associated with symptoms and symptom management, personal care, spiritual support, and family satisfaction. Structured, retrospective telephone interviews with family and staff who attended to NH and RC/AL residents in the last month of life. A stratified sample of 26 NH and 55 RC/AL facilities in four states. Family members (n=97) and long-term care (LTC) staff (n=104) identified as most involved in care of 124 residents who died over a 15-month period. A variety of reported measures of care and symptoms before death, including the Discomfort Scale for Dementia of the Alzheimer's Type. Of 124 decedents, 27 (22%) received hospice services. Dementia was less common in hospice enrollees than in decedents who did not receive hospice care. Hospice enrollees more often had moderate/severe pain and dyspnea and received pain treatment and were more likely to receive assistance with mouth care and eating and drinking. There were no differences related to unmet need, and observed differences were largely eliminated when comparisons were limited to residents whose deaths were expected. Rates of hospice use observed in this study (22%) were considerably higher than previously reported, although persons with dementia may continue to be underreferred. Hospice use is targeted to dying residents with higher levels of reported pain and dyspnea. Because difference in care largely disappears in cases when death was expected, LTC staff seem to be well positioned to provide end-of-life care for their residents and are advised to remain sensitive to instances in which death may be expected.

Family Satisfaction With Residential Care Provision: A Multilevel Analysis

The goal of this study was to assess the impact of staff commitment on outcomes of quality of care in residential care facilities in a sample of 260 family members of residents and 206 direct care staff from 24 residential care/assisted living (RC/AL) homes in Kansas. Quality of care was measured as family satisfaction, and individual- and facility-level predictors were used in the model. The significant predictors of family satisfaction were the family member’s age and relationship to elder. The findings suggest that both of these variables are tied to beliefs that family members have about their own responsibility for care, which may in turn influence their satisfaction with care. This hypothesis deserves further attention in future research. Also, the failure of this study to affirm an expected relationship between staff commitment and family satisfaction should prompt further research related to staff commitment and family satisfaction.

Introduction: Dementia Care and Quality of Life in Assisted Living and Nursing Homes

It is well recognized that the number of older adults who suffer from dementia has been increasing and will continue to do so over the coming years. In fact, nothing short of a three-fold rise in the number of people with Alzheimer’s disease is expected to occur between 2000 and 2050, and those with moderate or severe disease may number as many as 6.5 million midway through the century (Sloane et al., 2002). As the severity of dementia increases, families face challenging caregiving demands, and many find residential long-term care to be the best option for ongoing oversight. Historically, nursing homes have been the primary setting for the institutional care of older adults. During the last decade, however, their prominence in providing care for individuals who do not need medical services has been challenged by the growth of residential care/ assisted living (RC/AL)—facilities or discrete portions of facilities that are licensed by the states at a nonnursing home level of care, and provide room, board, 24-hour oversight, and assistance with activities of daily living. Recent estimates indicate that 23% to 42% of RC/AL residents have moderate or severe dementia, as do more than 50% of nursing home residents (Zimmerman et al., 2003). The number of RC/AL and nursing home beds exceeds 800,000 and 1.8 million, respectively (Institute on Medicine, 2001), suggesting that well more than 1 million individuals with dementia already reside in these settings. The matter of ‘‘quality’’ of life for individuals with dementia has been increasingly recognized during the last decade, and countless textbooks and manuals have been written to provide guidance on enhancing quality of life (see, for example, Fazio, Seman, & Stansell, 1999; Kovach, 1996; Volicer & Bloom-Charette, 1999). Efforts to define and measure this multidimensional component have progressed as well, and there now exist numerous valid and reliable instruments to do so (see, for example, Albert & Logsdon, 2000). What has been absent from the field is the study of quality of life for individuals with dementia in long-term care settings—both nursing homes and RC/AL facilities. Without this information, it has not been possible to evaluate components of care that relate to better quality of life. In this context, the work conducted by the Collaborative Studies of Long-Term Care (CSLTC) constitutes a significant contribution to what is known about quality of life and its correlates in long-term care. Another contribution of the work conducted by the CS-LTC is its basis in communitybased participatory research, which maximizes its utility for practice and policy. As detailed in the following ‘‘Perspectives of the Alzheimer’s Association,’’ the Association is using this information as the basis for its evidence-based consumer education, advocacy, and staff training efforts. Thus, the work presented in this issue is a necessary step toward the improvement of care and the quality of life for persons with dementia.

Health and Functional Outcomes and Health Care Utilization of Persons With Dementia in Residential Care and Assisted Living Facilities: Comparison With Nursing Homes

This study compares health and functional outcomes and health care utilization of persons with dementia residing in residential care/assisted living (RC/AL) facilities and nursing homes. The study uses data from a longitudinal cohort study of 1,252 residents with dementia in 106 RC/AL facilities and 40 nursing homes in four states. Rates of mortality; new or worsening morbidity; and change in activities of daily living, cognition, behavioral problems, depressive symptoms, social function, and withdrawal did not differ between the two settings. However, because of death or transfer, only about one half of the persons with mild dementia and one third of those with moderate to severe dementia remained in RC/AL facilities 1 year after enrollment. In addition, hospitalization rates were greater among individuals with mild dementia in RC/AL facilities, largely because of a medically unstable subgroup with high nursing-home-transfer rates. Many persons with dementia can be served equally well in either setting; however, those with major medical care needs may benefit from nursing home residence.

Families Filling the Gap: Comparing Family Involvement for Assisted Living and Nursing Home Residents With Dementia

The purpose of this study was to compare the sociodemographics, self-rated health, and involvement levels of family caregivers of residents with dementia in residential care/assisted living (RC/AL) versus nursing home settings. We conducted telephone interviews with the family caregivers most involved with 353 residents of 34 residential care and 10 nursing home facilities. We measured involvement by caregiver self-report of monthly out-of-pocket spending, involvement and burden ratings, and the frequency of engaging in eight specific care activities. Open-ended questions elicited areas in which caregivers preferred different involvement and ways the facility could facilitate involvement. Nursing home caregivers rated their health poorer than RC/AL caregivers, but there were no sociodemographic differences between the two. RC/AL caregivers rated both their perception of involvement and burden higher and engaged more frequently in monitoring the resident's health, well-being, and finances than did nursing home caregivers, although the reported time spent per week on care did not differ. RC/AL and nursing home caregivers to residents with dementia may tailor their care to fit the needs of the resident and setting. Results are discussed in relation to the Congruence Model of Person-Environment Fit.

Dementia Care and Quality of Life in Assisted Living and Nursing Homes

There are few empirical studies relating components of long-term care to quality of life for residents with dementia. This study relates elements of dementia care in residential care/assisted living (RC/AL) facilities and nursing homes to resident quality of life and considers the guidance this information provides for practice and policy. We used a variety of report and observational measures of the structure and process of care and 11 standardized measures of quality of life to evaluate the care for and quality of life of 421 residents with dementia in 35 RC/AL facilities and 10 nursing homes in four states. Data were collected cross sectionally on-site, and we conducted a 6-month follow-up by telephone. Change in quality of life was better in facilities that used a specialized worker approach, trained more staff in more domains central to dementia care, and encouraged activity participation. Residents perceived their quality of life as better when staff was more involved in care planning and when staff attitudes were more favorable. Better resident-staff communication was related to higher quality of life as observed and reported by care providers. Also, more stable resident-staff assignment was related to care providers' lower quality-of-life ratings. Improvement in resident quality of life may be achieved by improved training and deployment of staff.

Attitudes, Stress, and Satisfaction of Staff Who Care for Residents With Dementia

Considering the increasing proportion of residents in long-term care who have dementia, and the important influence that direct care providers have on resident quality of life, this study explores the dementia-related attitudes of residential care/assisted living (RC/AL) and nursing home staff, as well as their work stress and satisfaction. Data were derived from interviews with 154 direct care providers from 31 RC/AL facilities and 10 nursing homes who participated in the Collaborative Studies of Long-Term Care. Stress was more often reported by care providers who had been working for 1 to 2 years (compared with longer); in addition, those who had been working for 1 to 2 years were more likely to espouse hopeful or person-centered attitudes than those who had been working for a longer period of time. Also, a person-centered attitude related to satisfaction, and perceived competence in providing dementia care was consistently associated with dementia-sensitive attitudes and job satisfaction. Attending to the welfare and ongoing training of workers who have demonstrated job commitment may lessen their tendency to become jaded over time or seek job opportunities elsewhere. Further, the attitudes the staff hold related to dementia and the training they receive to provide dementia care are important for their own well-being.

Factors Associated With Nursing Assistant Quality-of-Life Ratings for Residents With Dementia in Long-Term Care Facilities

We identify resident, nursing assistant, and facility factors associated with nursing assistant quality-of-life ratings for residents with dementia in long-term care. We used a cross-sectional survey of 143 nursing assistants providing care to 335 residents in 38 residential care/assisted living (RC/AL) facilities and nursing homes in four states. We assessed resident quality of life by using the Quality of Life-Alzheimer's Disease Scale (QOL-AD). Scores on the quality-of-life scale were most strongly associated with resident clinical conditions, including severity of cognitive and functional impairments, depression, and behavioral symptoms of dementia. There was also an independent positive association between nursing assistants' ratings of resident quality of life and their own attitudes regarding dementia-person-centered care as well as training. However, the results of hierarchical linear modeling suggest that some sources of nursing assistant variability in quality-of-life ratings remain unidentified. Quality-of-life ratings by nursing assistants may be influenced by their attitudes about dementia and their confidence in addressing residents' fundamental care needs.

Medication undertreatment in assisted living settings.

Residential care/assisted living (RC/AL) is a rapidly growing, long-term care setting, where medication use has not been carefully examined. We sought to determine the prevalence and predictors of nonprescribing of selected medications whose value in decreasing morbidity has been established in clinical trials. As part of a survey of a stratified random sample of 193 RC/AL facilities in Florida, Maryland, New Jersey, and North Carolina, data were gathered on 2014 residents 65 years and older. Patient characteristics and diagnoses were recorded based on medical record reviews and in-person patient assessments; all medications administered at least 4 of the previous 7 days were recorded. Data on facility characteristics were obtained by interviewing facility administrators. Bivariate and multivariate logistic regression was performed to identify associations between medication nonprescribing and facility characteristics, physician visitation, and patient age, sex, race, comorbidity, functional dependency, and cognition. Of 328 subjects with congestive heart failure, 204 (62.2%) were not receiving an angiotensin-converting enzyme inhibitor; of 172 subjects with prior myocardial infarction, 60.5% were not receiving aspirin and 76.2% were not receiving beta-blockers; of 435 patients with history of stroke, 37.5% were not receiving an anticoagulant or antiplatelet agent; and of 315 patients with osteoporosis, 61.0% were not receiving calcium supplementation and 51.1% were not receiving any treatment for the condition. Resident age, race, sex, comorbidity, cognitive status, and dependency in activities of daily living were rarely associated with nonprescribing; in contrast, facility factors-particularly facility type and the frequency of physician visits-were somewhat more frequently associated with nonprescribing. Undertreatment appears to be prevalent in RC/AL facilities. Since preserving independence is often a primary goal of care in these settings, more attention may need to be paid to the use of treatments that have been shown to reduce long-term morbidity.

Behavioral symptoms in residential care/assisted living facilities: prevalence, risk factors, and medication management.

To examine the prevalence, correlates, and medication management of behavioral symptoms in elderly people living in residential care/assisted living (RC/AL) facilities. Cross-sectional study. A stratified random sample of 193 RC/AL facilities in four states (Florida, Maryland, New Jersey, North Carolina). A total of 2,078 RC/AL residents aged 65 and older. Behavioral symptoms were classified using a modified version of the Cohen-Mansfield Agitation Inventory. Additional items on resistance to care were also examined. Approximately one-third (34%) of RC/AL residents exhibited one or more behavioral symptoms at least once a week. Thirteen percent exhibited aggressive behavioral symptoms, 20% demonstrated physically nonaggressive behavioral symptoms, 22% expressed verbal behavioral symptoms, and 13% resisted taking medications or activities of daily living care. Behavioral symptoms were associated with the presence of depression, psychosis, dementia, cognitive impairment, and functional dependency, and these relationships persisted across subtypes of behavioral symptoms. Overall, behavioral symptoms were more prevalent in smaller facilities. More than 50% of RC/AL residents were taking a psychotropic medication, and two-thirds had some mental health problem indicator (dementia, depression, psychosis, or other psychiatric illness). Integrating mental health services within the process of care in RC/AL is needed to manage and accommodate the high prevalence of behavioral symptoms in this evolving long-term setting.

Social engagement and its relationship to service provision in residential care and assisted living

The purpose of this study was to categorize the underlying constructs of social activity participation in a residential care and assisted-living population, determine the extent of social engagement and how it varies by facility type, and relate social engagement to service provision. Data were collected far 2,078 residents of 193 facilities in Florida, Maryland, New Jersey, and North Carolina participating in the Collaborative Studies of Long-Term Care. An 11-item scale, the Assisted Living Social Activity Scale, was developed that was composed of three factors: private activities, group activities, and outings. Cognitive and functional status related to participation in these activities, visit and telephone contact, and social withdrawal. In adjusted analyses, differences by facility type were noted, and service provision related to social engagement in all areas except social withdrawal. Key words: assisted living; elderly people; residential care; service provision; social engagement ********** Residential care/assisted-living (RC/AL) facilities have become common residences for elderly people in need of assistance with activities of daily living (ADLs). In early 1998 approximately 11,500 RC/AL facilities provided care for more than 500,000 residents (Hawes, Rose, & Phillips, 1999); by 2010, it is estimated that these settings will provide care for more elderly people than do nursing homes (Meyer, 1998). Whereas RC/AL incorporates a wide variety of care, ranging from small mom-and-pop homes to large, apartment-style living facilities, these facilities have in common a social model of care, as opposed to the medical model on which nursing home care is based. The social model reflects principles such as providing or coordinating activities and services and encouraging family and community involvement in the life of the resident (Assisted Living Quality Coalition, 1998), two important components of engagement required for successful aging (Rowe & Kahn, 1998). Although the number of elderly people residing in RC/AL facilities is increasing, little is known about the social engagement of these residents and how well these facilities support residents' need for activity and social contact. The importance of examining social engagement and how the facility can optimize it is easily appreciated in light of the extensive evidence linking social relations to well-being (Berkman & Syme, 1979; Blazer, 1982; Lemke & Moos, 1986; Noelker & Harel, 1978). For example, involvement in activities is associated with decreased mortality rates (Rozzini, Bianchetti, Franzoni, Zanetti, & Trabucchi, 1991), the slowing of functional decline (Choi & Wodarski, 1996; Unger, Johnson, & Marks, 1997), increased happiness and quality of life (Graney, 1975; Ho et al., 1995), and decreased rates of stress and depression (Mitchell & Kemp, 2000; Patterson, 1996). The purpose of this study was to examine social engagement of residents in RC/AL facilities and the extent and variability of service provision in RC/AL and to determine whether there is an association between the provision of social or recreational activities and resident engagement. Although a thorough understanding of the broader concepts of social networks, social support, and social integration awaits further study, this article is the first to identify the underlying constructs of social activity participation among RC/ AL residents; to present a scale, the Assisted Living Social Activity Scale (AL-SAS), to quantify this participation; and to examine how participation and other areas of engagement (for example, visit and telephone contact and social withdrawal) relate to facility service provision. METHOD Sample and Design Data for this study were derived from the Collaborative Studies of Long-Term Care (CS-LTC), a four-state study of 2,078 RC/AL residents from 193 facilities in Florida, Maryland, New Jersey, and North Carolina. …

Inappropriate medication prescribing in residential care/assisted living facilities.

To identify the extent to which inappropriately prescribed medications (IPMs) are administered to older patients in residential care/assisted living (RC/AL) facilities and to describe facility and resident factors associated with receipt of one or more IPMs. Cross-sectional study of a stratified, representative sample of 193 facilities in four states. We identified representative geographic regions within Florida, New Jersey, North Carolina, and Maryland and drew from within them a stratified random sample of 193 RC/AL facilities. Three subtypes of facilities were included in the sample: small homes (<16 beds), larger "new-model" homes, and larger "traditional" homes. Within each larger home, a random sample of residents aged 65 and older was approached for consent; in smaller homes all residents were approached. The overall enrollment rate was 92%; 2,078 residents were enrolled. Questionnaires and on-site observations were used to gather data on facility administration and staffing and resident characteristics. All prescription and nonprescription medications taken at least 4 of the 7 days before data collection were taken from medication administration records and coded for analysis. IPM designation was based on modification of a list developed by Beers et al. and currently used by nursing home surveyors. The majority of RC/AL patients were taking five or more medications; 16.0% of these patients were receiving IPMs. The most common IPMs were oxybutynin, propoxyphene, diphenhydramine, ticlopidine, doxepin, and dipyridamole. In multivariate analyses, using generalized estimating equations, IPM use was associated with the number of medications received, smaller facility bed size, moderate licensed practical nurse turnover, absence of dementia, low monthly fees, and absence of weekly physician visits. IPMs remain a problem in long-term care, but rates in these RC/AL settings compare favorably with those reported for other frail older populations, suggesting that use of medications with severe adverse effects may be waning. Regular physician facility visits may improve prescribing, as will attention to high-risk groups such as individuals on multiple medications.