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UNC study: Assisted living communities home to more older adults with dementia

Findings stress additional training for staff and improved consumer education
In a first-of-its-kind national study, UNC-Chapel Hill researchers have confirmed that assisted living communities are a primary provider of residential care for older adults with dementia and that an estimated 7 out of 10 adults in these residences have some form of cognitive impairment. With these findings in mind, researchers recommended that assisted living homes consider more training for staff, especially in medication management and avoiding the use of medications to control behavior, and stressed recent recommendations that call for improved public education to help consumers better understand the varied policies and practices of assisted living.
The research study, which was published this month in the journal Health Affairs, is based on a review of the 2010 National Survey of Residential Care Facilities. The study involved 2,300 assisted living residences from across the country and is the first time that data have been collected on a national scale to assess dementia prevalence and care in assisted living—communities that are currently regulated by states.

Sheryl Zimmerman, Ph.D.

As of 2010, assisted living residences across the country provided care to an estimated 733,000 older adults. According to the study, 42 percent of these residents, or more than 300,000 adults, were characterized as having dementia, or symptoms that affect an individual’s ability to think clearly. 
“Although multi-state studies and single state studies have looked at dementia, what the prevalence is, and related policy and practice issues, the national figures did not exist until now. So these results help to clarify the scope of what we’ve been seeing from other studies,” explained Sheryl Zimmerman, a distinguished professor in the Schools of Social Work and Public Health at the University of North Carolina at Chapel Hill. Zimmerman, who is also co-director of the Program on Aging, Disability, and Long-Term Care at the Cecil G. Sheps Center for Health Services Research, collaborated on the study with Sheps Center colleagues, Philip D. Sloane, program co-director and a distinguished professor in the UNC Department of Family Medicine; and David Reed, a research associate.
The UNC study also examined dementia-specific care, also known as memory care, in assisted living residences. Researchers found that most adults in assisted living are not residing in dementia special-care units because most, or 83 percent, did not have such specialty units. Zimmerman cautioned that the lack of specialized care, which is generally more expensive, does not necessarily equate to poorer outcomes for residents with dementia. In fact, her previous research has found that residents benefit more from best practices such as pleasant sensory stimulation and individualized care, than residing in special dementia care units.
In the current study, researchers did find that assisted living communities, in general, are housing residents who have greater cognitive impairments and as a result, need more and more care. Specifically, the study found that almost a quarter of adults in assisted living have a moderate impairment and a fifth have a severe impairment, meaning they required assistance with various daily activities such as bathing, eating, dressing, or taking medication.
“Many of the people in assisted living today would have been in nursing homes ten years ago,” Zimmerman said. “Hospitals discharge people sooner, meaning that nursing homes are taking care of sicker people. In turn, people in nursing homes who don’t need 24/7 nursing care now live in assisted living. So it’s no surprise that people in assisted living have more needs than they used to.”
Although the UNC study didn’t address the extent that these needs are met, researchers suggested that additional staff training and best practices should be encouraged to ensure that employees better recognize dementia and changes in residents’ behavior and can respond to them. The need for training is illustrated by the finding that 69 percent of all assisted living residences regularly gave out medications to control behavior, Zimmerman noted. These data do not suggest that places are “automatically” prescribing drugs when there are problems, but they do show that that they are giving medications, which is reason to pause, Zimmerman said.
“Just because someone is agitated doesn’t mean that you automatically give them medication to calm them down,” she said. “That’s not supposed to be the first line of activity.”
Rather, more attention should be given to the possible cause of an individual’s behavior, she added. “Are they hot? Are they cold? Are they hungry? Is there too much stimulation?” Zimmerman asked.
“What all this really says at this point is that we need to better understand when medications are being given and what for and are there better things that could be done instead, which folds right back into staff training.”
Medication training also is important because in one-fifth of residences, untrained staff are administering medications. Zimmerman’s other research has found that untrained staff make more errors in medication administration, suggesting that any staff who handle medications be trained to the level of a medication aide or technician, the current requirement in North Carolina.
Given that assisted living residences are so variable, UNC researchers also recommended that the public become more aware of their services, policies, and costs. Among other issues, consumers should know about admitting and discharge policies, which can vary from residence to residence and may not always be publicly disclosed, Zimmerman said.
“Some of these things will actually matter for care, but consumers don’t always know to ask,” she said. Zimmerman and Sloane helped shed some light on this issue in North Carolina last year with the creation of a searchable website that offers detailed information about assisted living residences in the state. The goal is to help consumers find the right home that best meets the needs of older adults and hopefully, promotes quality of life. Ultimately, having a more educated public on the role of these communities benefits everyone, Zimmerman said.
“The fact is this industry has become a huge long-term care provider for older adults, and if assisted living isn’t doing it, then where will these people get supportive care?”  
By Susan White