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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]

We used a cross-sectional study to examine the correlates of caregiver-rated quality of life (QOL) in 198 randomly selected residents from a stratified random sample of 22 assisted living facilities in central Maryland. We measured QOL by using the Alzheimer's Disease-Related Quality of Life Questionnaire. In general, despite cognitive impairment, residents in assisted living were rated as having a high QOL. In a multivariate regression, we found that nonmood neuropsychiatric symptoms were the strongest correlate of QOL, explaining 37% of the variance. Depressive symptoms, functional dependence, marital status, and cognition also contributed to the model, but only minimally. Because of the strong association of neuropsychiatric symptoms with QOL, special attention should be given to their recognition and amelioration. [ABSTRACT FROM AUTHOR]

(See editorial comments by Drs. Kathy Ruckdeschel and Ira Katz on pp 1771–1773)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 theDiagnostic 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. [ABSTRACT FROM AUTHOR]

Background: Although increasing numbers of older adults are living in assisted living facilities, there is little information on the types and amount of chronic medical illness and the medications required by such residents. To better inform efforts to optimize care in this setting, we sought to quantify chronic medical illnesses and their treatment. Methods: Medical diagnoses and treatments were derived from chart reviews and interviews of 198 residents of 22 randomly selected assisted living facilities (AL) in central Maryland. To evaluate the burden of medical illnesses, chronic conditions were categorized and quantified according to general (organ system) diseases, as well as 7 specific long-term care Clinical Practice Guidelines (CPG). Using logistic regression, we calculated the associations between facility-level characteristics and those residents with a) conditions from 3 or more general disease categories and, b) 2 or more CPG conditions. To evaluate medical treatment complexity, we categorized oral and certain non-oral medications, as well medications that typically require additional monitoring. Results: Almost one-half (46%) of AL residents had chronic conditions in 3 or more different general disease categories and one-fourth (25.2%) had 2 or more specific Clinical Practice Guideline (CPG) conditions. Residents with chronic conditions in 3 or more different general disease groups were more likely to live in larger facilities; otherwise, no other facility-level characteristics that we assessed were associated with residents having conditions from 3 or more general disease categories or 2 or more CPG conditions. One-half of all residents were taking medications that typically require additional monitoring and 25% of residents were receiving treatments of respiratory inhalers, eye drops and/or injections. Conclusions: Many AL residents have multiple medical illnesses of different types and complexity. Given the increasing role of AL providers in the management of such conditions, appropriate adjustments in care provision will be needed for facilities to meet the needs of these residents. [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]

Background: There is a lack of empirical evidence about the impact of regulations on dementia care quality in assisted living (AL). We examined cohort differences in dementia recognition and treatment indicators between two cohorts of AL residents with dementia, evaluated prior to and following a dementia-related policy modification to more adequately assess memory and behavioral problems., Methods: Cross-sectional comparison of two AL resident cohorts was done (Cohort 1 [evaluated 2001-2003] and Cohort 2 [evaluated 2004-2006]) from the Maryland Assisted Living studies. Initial in-person evaluations of residents with dementia (n = 248) were performed from a random sample of 28 AL facilities in Maryland (physician examination, clinical characteristics, and staff and family recognition of dementia included). Adequacy of dementia workup and treatment was rated by an expert consensus panel., Results: Staff recognition of dementia was better in Cohort 1 than in Cohort 2 (77% vs. 63%, p = 0.011), with no significant differences in family recognition (86% vs. 85%, p = 0.680), or complete treatment ratings (52% vs. 64%, p = 0.060). In adjusted logistic regression, cognitive impairment and neuropsychiatric symptoms correlated with staff recognition; and cognitive impairment correlated with family recognition. Increased age and cognitive impairment reduced odds of having a complete dementia workup. Odds of having complete dementia treatment was reduced by age and having more depressive symptoms. Cohort was not predictive of dementia recognition or treatment indicators in adjusted models., Conclusions: We noted few cohort differences in dementia care indicators after accounting for covariates, and concluded that rates of dementia recognition and treatment did not appear to change much organically following the policy modifications.

Background: To estimate the 12-month incidence, prevalence, and persistence of mental disorders among recently admitted assisted living (AL) residents and to describe the recognition and treatment of these disorders., Methods: Two hundred recently admitted AL residents in 21 randomly selected AL facilities in Maryland received comprehensive physician-based cognitive and neuropsychiatric evaluations at baseline and 12 months later. An expert consensus panel adjudicated psychiatric diagnoses (using DSM-IV-TR criteria) and completeness of workup and treatment. Incidence, prevalence, and persistence were derived from the panel's assessment. Family and direct care staff recognition of mental disorders was also assessed., Results: At baseline, three-quarters suffered from a cognitive disorder (56% dementia, 19% Cognitive Disorders Not Otherwise Specified) and 15% from an active non-cognitive mental disorder. Twelve-month incidence rates for dementia and non-cognitive psychiatric disorders were 17% and 3% respectively, and persistence rates were 89% and 41% respectively. Staff recognition rates for persistent dementias increased over the 12-month period but 25% of cases were still unrecognized at 12 months. Treatment was complete at 12 months for 71% of persistent dementia cases and 43% of persistent non-cognitive psychiatric disorder cases., Conclusions: Individuals recently admitted to AL are at high risk for having or developing mental disorders and a high proportion of cases, both persistent and incident, go unrecognized or untreated. Routine dementia and psychiatric screening and reassessment should be considered a standard care practice. Further study is needed to determine the longitudinal impact of psychiatric care on resident outcomes and use of facility resources.

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 than 1 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.

Anxiety is a distressing experience at any age but may be particularly disabling when coupled with dementia. Dementia-related anxiety is associated with a range of additional problems among community-dwelling older adults, but little is known about its occurrence in assisted living environments. The purpose of this article is to describe the prevalence of anxiety symptoms among older adults who participated in Phase I of the Maryland Assisted Living Study, a cross-sectional study of 198 participants who underwent comprehensive dementia evaluations. Participants with dementia diagnoses (n=134) were compared with those without dementia (n=64) using two measures of anxiety. Anxiety was common in both groups: 22% of each group were assessed to have one or more anxiety symptoms using proxyrated methods, and 45% had at least mild anxiety using direct observation and interview. Factors that contribute to variability in reports of dementia-related anxiety are reviewed., (Copyright (c) 2008, SLACK Incorporated.)

Objectives: This study's goal was to identify factors associated with providing either informed consent or assent for research in individuals at high risk for cognitive impairment., Design: Cross-sectional baseline data were used to identify predictors of consent or assent status., Setting: The study was conducted at 22 assisted living facilities in Maryland., Participants: A stratified random sample of 198 assisted living residents participated in the study., Measurements: Residents' consent or assent status was documented as providing informed consent, written assent, or verbal assent/no objection. Potential predictors included residents' demographic characteristics, measures of physical and mental health status, and neuropsychological test performance., Results: Most participants provided written assent (32.8%) or verbal assent/no objection (30.3%) rather than informed consent (36.9%). Although many resident characteristics correlated with consent or assent status based on bivariate analyses, few variables distinguished those who provided written assent from those in the verbal assent/no objection group. On the basis of multiple discriminant analysis, the best predictors of consent or assent status were Mini-Mental State Exam scores, impairments in instrumental activities of daily living, and dementia diagnosis, which together classified correctly 63.6% of residents., Conclusions: The relatively small proportion of participants who could provide informed consent highlights the importance of assessing decisional capacity for research in a high-risk population and identifying an appropriate surrogate decision maker to provide proxy consent if needed. Consensus on how to define assent is lacking, and specific measures of assent capabilities are needed to better characterize the assent capacity continuum.

Objective: Assisted living (AL) is a rapidly expanding residential option for the senior population. With increased utilization, it becomes important to understand the detection and treatment of dementia in this setting, but little is known. The objective of this study was to identify and evaluate factors associated with caregiver unawareness of dementia and failure to treat dementia in AL., Methods: The setting was a cross-sectional study of a random sample of AL facilities in central Maryland (The Maryland Assisted Living Study). Geriatric psychiatrists evaluated 198 participants and assigned dementia diagnoses to 134 residents (67.7%). The extent to which dementia was recognized and treated in these facilities was estimated on the basis of caregiver interview and chart review data. Using logistic regression models, demographic, cognitive, and functional measures were evaluated as predictors of caregiver unawareness and nontreatment of dementia., Results: Severity of cognitive and functional impairment, number of neuropsychiatric symptoms, and male gender were all independent predictors of caregiver unawareness of dementia. Family and caregiver unawareness of dementia and female gender were predictors of failure to treat dementia. Detection and treatment were not associated with race, age, or overall medical health., Conclusions: Caregivers were more likely to be unaware of dementia in residents who did not have severe cognitive impairment or obvious behavioral and functional problems. Caregiver and family unawareness were in turn associated with nontreatment. Observed gender differences in detection and treatment will require replication and further study. These observations suggest that systematic educational interventions for caregivers and families may improve detection and hence treatment in the AL setting.

Introduction: 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., Objective: 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)., Methods: 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., Results: 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., Conclusion: 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., (Copyright (c) 2005 John Wiley & Sons, Ltd.)

Background: Assisted living is a popular residential option for older individuals, yet little research has been done on people choosing this option. This study examines predictors of functional impairment in assisted living residents in the domains of cognition, mood, and health., Methods: An experienced team of neuropsychiatrists, nurses, and technicians using a number of cognitive, behavioral, health, and functional status tests and a cross-sectional study design assessed 198 residents of 22 assisted living facilities in Maryland. Data from these evaluations were used in univariate and multiple regression models to identify predictors of functional impairment, operationalized as the sum of the scores on two scales, one measuring impairment in basic activities of daily living and one measuring impairment in instrumental activities of daily living., Results: Greater cognitive impairment, worse depression, and worse medical health were significant independent predictors of functional impairment, together explaining a sizeable portion of the variance (adjusted R2=0.434). None of the demographic variables examined individually, including age and education, was predictive of functional impairment. In an analysis of specific cognitive domains, executive dysfunction, impairment of visuospatial skills, and amnesia were significant predictors of impairment, whereas inattention was not., Conclusion: Executive dysfunction, apraxia, memory impairment, depression, and general medical health are all significant predictors of functional impairment in assisted living residents, with executive dysfunction being the strongest. These results may be instrumental in developing a more efficient model of care for residents of assisted living facilities, one based on having accurate predictive models of degree of impairment.

Background: The course of depression in residents of long-term care with dementia is not well studied., Objectives: To estimate the incidence, prevalence, and outcomes of depression in long-term care residents with dementia., Method: 201 residents of Copper Ridge, a long-term care facility for the memory impaired, were followed every six months during the first year after their admission., Results: On admission 19.9% of the residents had depression, the majority (75%) occurring in persons with a prior history of depression. At six months, only 15% of the original 40 depressed patients were still depressed, while at twelve months only 7.5% were depressed. The incidence of depression at six and twelve months was 1.8% and 6.4% respectively. Most persons with new depression at six months were no longer depressed at one year. The annual attack rate (cumulative likelihood of depression over one year) for the total population was 26.4%. The rates for the subgroup of Alzheimer's were similar to the rates of the total population, except for an annual attack rate of 17.5%, reflecting a lower rate of depression on admission. The decline in depression over the year after admission is noteworthy and likely reflects appropriate diagnosis and treatment of depression., Conclusions: These results indicate that, over the course of one year, depression afflicts a considerable proportion of long-term care residents with dementia. Admission to a long-term care facility may actually result in a reduction of depression within the year after admission in part due to rapid recognition, appropriate diagnosis and treatment., (Copyright 2002 John Wiley & Sons, Ltd.)