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Purpose: Many residents of assisted living (AL) have chronic diseases that are difficult to manage, including congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM). We estimated the amount and intensity of care delivered by the staff for residents with these conditions. Methods: We performed a secondary data analysis from the Maryland Assisted Living (MDAL) Study (399 residents, 29 facilities). In-person assessments included measures of cognition, function, depression, and general medical health. Diagnosis of CHF, COPD, and DM, as well as current medications was abstracted from AL medical charts. Measures of care utilization were operationalized at the resident level as: 1 ) minutes per day of direct care (caregiver activity scale [CAS]), 2) subjective staff ratings of care burden, and 3) assigned AL "level of care" (based on state regulatory criteria). Results: In best fit regression models, CHF and DM were not significant predictors of the evaluated care utilization measures; however, COPD was independently associated with increased minutes per day of direct care - 34% of the variance in the caregiver activity scale was explained by degree of functional dependency, cognitive impairment, age, and presence of COPD. Functional dependency, depressive symptoms, and age explained almost a quarter (23%) of the variance of staff care burden rating. For the AL level of care intensity rating, degree of functional dependency, level of cognition, and age were significant correlates, together explaining about 28% of the variance. Conclusion: The presence of COPD was a significant predictor of time per day of direct care. However, CHF and DM were not correlates of care utilization measures. Functional and cognitive impairment was associated with measures of care utilization, reiterating the importance of these characteristics in the utilization and intensity of care consumed by AL residents. Further study of this population could reveal other forms and amounts of care utilization. [ABSTRACT FROM AUTHOR]

Objective Although the number of elderly residents living in assisted living (AL) facilities is rising, few studies have examined the AL physical environment and its impact on resident well-being. We sought to quantify the relationship of AL physical environment with resident outcomes including neuropsychiatric symptoms (NPS), quality of life (QOL), and fall risk, and to compare the effects for demented and non-demented residents. Methods Prospective cohort study of a stratified random sample of 326 AL residents living in 21 AL facilities. Measures included the Therapeutic Environmental Screening Scale for Nursing Homes and Residential Care (TESS-NH/RC) to rate facilities and in-person assessment of residents for diagnosis (and assessment of treatment) of dementia, ratings on standardized clinical, cognitive, and QOL measures. Regression models compared environmental measures with outcomes. TESS-NH/RC is modified into a scale for rating the AL physical environment AL-EQS. Results The AL Environmental Quality Score (AL-EQS) was strongly negatively associated with Neuropsychiatric Inventory (NPI) total score (p < 0.001), positively associated with Alzheimer Disease Related Quality of Life (ADRQL) score (p = 0.010), and negatively correlated with fall risk (p = 0.042). Factor analysis revealed an excellent two-factor solution, Dignity and Sensory. Both were strongly associated with NPI and associated with ADRQL. Conclusion The physical environment of AL facilities likely affects NPS and QOL in AL residents, and the effect may be stronger for residents without dementia than for residents with dementia. Environmental manipulations that increase resident privacy, as well as implementing call buttons and telephones, may improve resident well-being. Copyright © 2010 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives To describe patterns of Acetylcholinesterase inhibitor (ACI) use in an Assisted Living (AL) population, and the association of ACIs with retention in AL. Methods As part of the Maryland Assisted Living Study (MD–AL), 198 residents of 22 ALs were evaluated. Dementia was diagnosed in 134, and specifically Alzheimer's disease (AD) in 79, by an expert consensus panel. Data was collected on ACI agent and dose. Vital status and location were recorded every 6 months. Other data included age, duration of residence, general medical health rating (GHMR), Mini-Mental State Examination (MMSE), Neuropsychiatric Inventory (NPI), Cornell Scale for Depression in Dementia (CSDD) and number of non-psychiatric medications. Results The overall ACI treatment rate was 31%. 34.5% of participants with mild to moderate AD were taking ACIs. Only two in seven participants taking rivastigmine were taking an adequate dose. Participants with AD on ACI's did not differ significantly from those not on ACI's in any of the secondary measures except age and duration of residence, those on the agents being somewhat younger and more recently admitted. For participants with AD, only ACI use was significantly associated with retention in AL at 6 months, with a relative risk of death or discharge to higher level care of 0.217. Baseline MMSE was associated with retention for those with non-AD dementia. In a survival analysis ACI use was associated with 228.75 days longer retention in participants with AD. Conclusion ACIs have low rates of use in AL and are associated with better retention for residents with AD. Copyright © 2007 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective To estimate the frequency and correlates of insomnia and daytime sleepiness among people with dementia in AL facilities. Methods Participants were randomly selected from 22 different assisted living facilities in Maryland. A total of 124 dementia participants were included in the analysis. All participants were rated on an 11-item sleep questionnaire regarding insomnia and daytime sleepiness. Results Sleep disturbance was present in 59.2% of people with dementia. Of the total sample, 21.8% had insomnia only (IN); 21.6% had excessive daytime sleepiness only (DS); and 16.8% had both IN and DS. 40.8% had no sleep disturbance. IN and DS scores were not significantly associated with each other (r = 0.07, p = 0.43). Of those in the IN group, the majority had mild and moderate dementia and of those in the DS only group the majority had severe dementia. Those with IN only performed the best and DS only performed the worst on both cognitive measures (the Mini Mental State Examination) (F = 3.26, p = 0.014), and on physical measures (the physical subscale of the psychogeraitric dependency rating scale) (F = 6.09, p < 0.001). There was no significant difference between the groups on the Cornell scale for depression in dementia. Conclusion The frequency of insomnia and daytime sleepiness in dementia subjects in AL is similar to that found in nursing homes. Daytime sleepiness is associated with poorer cognitive and day-to-day functioning. Effective management of DS may lead to improved functioning in the AL residents. Insomnia is associated with the best outcomes, even better than those with no sleep disturbance. This finding needs to be replicated. Copyright © 2007 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To estimate the association between dementia and time to discharge from individual assisted living (AL) facilities and examine, in residents with dementia, factors associated with shorter duration of residence in individual AL facilities. DESIGN: Prospective cohort study. SETTING: Twenty-two AL facilities in central Maryland. PARTICIPANTS: Stratified random sample of 198 AL residents followed for a median of 18 months. MEASUREMENTS: Detailed assessments to diagnose dementia; assess treatment of dementia; and rate clinical; cognitive, functional, and quality-of-life measures. RESULTS: Residents with dementia remained in a facility 209 fewer days at the median ( P=.001) than residents without dementia. After adjustment for other variables, lack of treatment for dementia ( P=.01) and more-serious medical comorbidity ( P=.02) were associated with earlier discharge in participants with dementia. Impaired mobility and limited activity participation had weaker associations with earlier time to discharge. CONCLUSION: Dementia may accelerate time to discharge, and its treatment may attenuate this effect. The hypothesis that the detection and treatment of dementia might delay discharge from AL should be tested in randomized trials. [ABSTRACT FROM AUTHOR]

Objectives To compare the demographic, clinical, and psychiatric characteristics of residents living in small (≤15 beds) and large assisted living (AL) facilities in the United States. Methods One hundred and ninety-eight residents in 10 large and 12 small assisted living facilities were comprehensively assessed as part of the Maryland Assisted Living Study (MD-AL). The presence or absence of dementia and psychiatric disturbances and the facilities' recognition and management of these disorders were compared across the two types of AL. Aspects of care delivery were also compared. Results Small facilities had a higher prevalence of dementia (81%) compared to larger facilities (63%) and the mean Mini-Mental State Examination (MMSE) across all residents in small facilities (mean 13.04) was than in large facilities (mean 19.93)(p = 0.000). Almost all (98%) of the residents of small homes carried a diagnosis of a dementia or other psychiatric diagnosis, compared to 74% of residents in large facilities (p < 0.001). Psychosis in particular was more prevalent in the smaller homes and the mean Neuropsychiatric Inventory score, a measure of neuropsychiatric symptoms, was higher compared to large homes. Falls were more common in larger homes despite a greater number of personal care hours per week. The use of safety devices and restraints was significantly less common in large facilities compared to smaller homes, where ‘geri-chair’ and bedrails were more often used. Conclusions Rates of dementia and psychiatric disorder differ in assisted living facilities depending on size of facility. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

IntroductionA 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. ObjectiveTo 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). MethodsParticipants 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. ResultsSleep 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. ConclusionThe 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. Copyright © 2005 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objectives: To describe and contrast functional dependency (FD) levels among recently admitted AL residents with and without dementia and to assess the differential contribution of cognitive, behavioral, medical, and social factors on FD within each group. Design: A cross-sectional study. Setting: A random sample of 28 AL facilities in the Central Maryland region. Participants: Two hundred and sixty-two AL residents assessed less than1 year after admission. Measurements: Participants were given comprehensive in-person dementia assessments. Cognitive, behavioral, medical, and social factors were also assessed. FD was operationalized as impairment in activities of daily living. Results: The 59% of residents with dementia had higher levels of FD (P < .001) and were more likely to require assistance in all assessed task-specific ADL domains (P < .001) except mobility (P = .653). In multivariate models, global cognition, medical health status, and presence of diabetes explained 43% of the variance in FD in the dementia group. Twenty-five percent of the variance in FD was explained by depression, neuropsychiatric symptoms, and global cognition in those without dementia. Conclusions: Recently admitted AL residents have substantial levels of FD. FD is higher among residents with dementia compared with those without and the association of cognitive, mental health, and medical variables with FD differ as a function of dementia status. Future research should examine how these dimensions affect FD longitudinally and whether they may serve as targets for interventions and quality of care improvement initiatives. [Copyright &y& Elsevier]

Objectives: To examine risk factors for transition from assisted living (AL) care to skilled nursing facility (SNF) care in a random sample of adults residing in AL. Design: Baseline clinical evaluation and telephone follow-up at 6-month intervals for up to 36 months. Setting: AL facilities in central Maryland. Participants: There were 198 participants randomly sampled from AL facilities stratified by facility size. Measurements: Consensus diagnoses by multidisciplinary geriatric psychiatry team as well as a broad range of neuropsychiatric and functional scales including Neuropsychiatric Inventory, Cornell Scale for Depression in Dementia, Mini-Mental State Exam, and Alzheimer’s Disease Related Quality of Life Scale, as well as cognitive tests. Possible risk factors for transition to SNF were assessed in Cox proportional-hazards multivariate regression methods, using a P value less than .05 for statistical significance. Results: Twenty-nine participants transitioned to SNF care. Mean AL survival time from baseline evaluation was 0.8 (SD 0.6) years for residents transitioned to SNF and 1.4 (SD 0.7) years for residents remaining in AL at follow-up. Risk factors for transition to SNF included declining health, chronic pain, appetite changes, and being widowed, while insomnia was protective against transition to SNF. Surprisingly, dementia and neuropsychiatric symptoms did not increase risk of transition to SNF. Conclusion: Survival time in AL is determined by factors similar to those operating on community-dwelling elderly, but dementia and neuropsychiatric symptoms do not alter survival time. [Copyright &y& Elsevier]