Sociocultural Aspects of Transitions From Assisted Living for Residents With Dementia

Admission and Discharge Practices Among Assisted Living Communities: The Role of State Regulations and Organizational Characteristics

BACKGROUND AND OBJECTIVES

A better understanding of factors associated with assisted living admission and discharge practices can help identify communities that are more likely to allow residents to age in place. This study examined how state regulations and assisted living organizational characteristics related to community admission and discharge practices for bathing, getting out of bed, and feeding.

RESEARCH DESIGN AND METHODS

Using data from a representative sample of 250 assisted living communities in seven states and a database of assisted living state regulations, we employed multilevel logistic regression models to examine regulatory and organizational correlates of assisted living community admission and discharge practices for 3 activities of daily living (bathing, getting out of bed, and feeding).

RESULTS

States' regulations were not associated with assisted living community admission and discharge practices. However, assisted living communities above the median in the number of personal care staff members per resident were 17% (95% confidence interval [CI]: 6.5%, 27.1%) more likely to admit residents who needed assistance with feeding and 25.4% (95% CI: -37.7, -13.2) less likely to discharge these residents. For-profit communities were more likely to admit residents with bathing and feeding limitations.

DISCUSSION AND IMPLICATIONS

Organizational characteristics (e.g., for-profit affiliation, staffing levels) may, in part, drive admission and discharge practices, especially related to different care needs. The ability to house residents with advanced care needs may be influenced more by the organizational resources available to care for these residents than by states' admission and discharge regulations.

Does Assisted Living Provide Assistance And Promote Living?

Assisted living has promised assistance and quality of living to older adults for more than eighty years. It is the largest residential provider of long-term care in the United States, serving more than 918,000 older adults as of 2018. As assisted living has evolved, the needs of residents have become more challenging; staffing shortages have worsened; regulations have become complex; the need for consumer support, education, and advocacy has grown; and financing and accessibility have become insufficient. Together, these factors have limited the extent to which today's assisted living adequately provides assistance and promotes living, with negative consequences for aging in place and well-being. This Commentary provides recommendations in four areas to help assisted living meet its promise: workforce; regulations and government; consumer needs and roles; and financing and accessibility. Policies that may be helpful include those that would increase staffing and boost wages and training; establish staffing standards with appropriate skill mix; promulgate state regulations that enable greater use of third-party services; encourage uniform data reporting; provide funds supporting family involvement; make community disclosure statements more accessible; and offer owners and operators incentives to facilitate access for consumers with fewer resources. Attention to these and other recommendations may help assisted living live up to its name.

Association Between State Regulations Supportive of Third-party Services and Likelihood of Assisted Living Residents in the US Dying in Place

Importance

Older adults are increasingly residing in assisted living residences during their last year of life. The regulations guiding these residential care settings differ between and within the states in the US, resulting in diverse policies that may support residents who wish to die in place.

Objective

To examine the association between state regulations and the likelihood of assisted living residents dying in place. The study hypothesis was that regulations supporting third-party services, such as hospice, increase the likelihood of assisted living residents dying in place.

Design, Setting, and Participants

This retrospective cohort study combined data about assisted living residences in the US from state registries with an inventory of state regulations and administrative claims data. The study participants comprised 168 526 decedents who were Medicare beneficiaries, resided in 8315 large, assisted living residences (with ≥25 beds) across 301 hospital referral regions during the last 12 months of their lives, and died between 2017 and 2019. Descriptive analyses were performed at the state level, and 3-level multilevel models were estimated to examine the association between supportive third-party regulations and dying in place in assisted living residences. The data were analyzed from September 2021 to August 2022.

Exposures

Supportive (vs "silent," ie, not explicitly mentioned in regulatory texts) state regulations regarding hospice care, private care aides, and home health services, as applicable to licensed/registered assisted living residences across the US.

Main Outcomes and Measures

Presence in assisted living residences on the date of death.

Results

The median (IQR) age of the 168 526 decedents included in the study was 90 (84-94) years. Of these, 110 143 (65.4%) were female and 158 491 (94.0%) were non-Hispanic White. Substantial variation in the percentage of assisted living residents dying in place was evident across states, from 18.0% (New York) to 73.7% (Utah). Supportive hospice and home health regulations were associated with a higher odds of residents dying in place (adjusted odds ratio [AOR], 1.38; 95% CI, 1.24-1.54; P < .001; and AOR, 1.21; 95% CI, 1.10-1.34; P < .001, respectively). In addition, hospice regulations remained significant in fully adjusted models (AOR, 1.46; 95% CI, 1.25-1.71).

Conclusions and Relevance

The findings of this cohort study suggest that a higher percentage of assisted living residents died in place in US states with regulations supportive of third-party services. In addition, assisted living residents in licensed settings with regulations supportive of hospice regulations were especially likely to die in place.

Stakeholder involvement in care transition planning for older adults and the factors guiding their decision-making: a scoping review

OBJECTIVE

To synthesise the existing literature on care transition planning from the perspectives of older adults, caregivers and health professionals and to identify the factors that may influence these stakeholders' transition decision-making processes.

DESIGN

A scoping review guided by Arksey and O'Malley's six-step framework. A comprehensive search strategy was conducted on 7 January 2021 to identify articles in five databases (MEDLINE, Embase, CINAHL Plus, PsycINFO and AgeLine). Records were included when they described care transition planning in an institutional setting from the perspectives of the care triad (older adults, caregivers and health professionals). No date or study design restrictions were imposed.

SETTING

This review explored care transitions involving older adults from an institutional care setting to any other institutional or non-institutional care setting. Institutional care settings include communal facilities where individuals dwell for short or extended periods of time and have access to healthcare services.

PARTICIPANTS

Older adults (aged 65 or older), caregivers and health professionals.

RESULTS

39 records were included. Stakeholder involvement in transition planning varied across the studies. Transition decisions were largely made by health professionals, with limited or unclear involvement from older adults and caregivers. Seven factors appeared to guide transition planning across the stakeholder groups: (a) institutional priorities and requirements; (b) resources; (c) knowledge; (d) risk; (e) group structure and dynamic; (f) health and support needs; and (g) personality preferences and beliefs. Factors were described at microlevels, mesolevels and macrolevels.

CONCLUSIONS

This review explored stakeholder involvement in transition planning and identified seven factors that appear to influence transition decision-making. These factors may be useful in advancing the delivery of person and family-centred care by determining how individual-level, group-level and system-level values guide decision-making. Further research is needed to understand how various stakeholder groups balance these factors during transition planning in different health contexts.

Variability and Potential Determinants of Assisted Living State Regulatory Stringency

OBJECTIVES

We examined state variations in assisted living (AL) regulatory policies for admission/retention, staffing/training, medication management, and dementia care. Factors associated with domain-specific and overall regulatory stringency were identified.

DESIGN

This observational study used the following data sources: 2019 review of state AL regulations; 2019 national inventory of AL communities; 2014 Government Accountability Office survey of Medicaid agencies; 2016 Genworth Cost of Care Survey; and the 2018 Nursing Home Compare.

SETTING AND PARTICIPANTS

Final analyses included 46 states (excluding Alaska, Kentucky, Louisiana, and West Virginia) and the District of Columbia.

METHODS

For each regulatory domain of interest (dependent variables), we generated policy scores by conducting content analysis of state regulatory databases. States were assigned points for presence of each policy (eg, staff training). The number of points assigned to each policy was divided by the total possible number of policy-related points, producing state stringency scores (between 0% and 100%) for each policy domain. Independent variables included market-level characteristics (eg, AL monthly cost), state generosity (eg, proportion of Medicaid aged using AL services), quality of care (eg, percent of nursing homes with few deficiencies), and others. Descriptive analyses and multivariable logistic regression models with stepwise selection were used.

RESULTS

We found significant variations in all policy domains across states. No single policy appeared to clearly dominate a state's rank. AL bed supply, monthly AL cost, proportion of Medicaid beneficiaries receiving AL services, and other variables were significantly associated with regulatory stringency of the domains examined.

CONCLUSIONS AND IMPLICATIONS

There were substantial variations in regulatory stringency across states. Several market and state generosity measures were identified as potential determinants of stringency, but the direction of these associations appeared to depend on what was being regulated. Future studies should examine how regulatory stringency affects access to and care quality in ALs.

Stronger Impact of Interpersonal Aspects of Satisfaction Versus Tangible Aspects on Sustainable Level of Resident Loyalty in Continuing Care Retirement Community: A Case Study

The objectives of the study were to examine the impact of interpersonal and tangible aspects of resident satisfaction on word-of-mouth (WOM) intention in community-embedded third places with long-duration service experiences and to investigate the mediating effect of interpersonal aspects on the relationship between tangible resident satisfaction and WOM intention. Paper-based survey questionnaires and postage-paid envelopes were mailed to 293 continuing care retirement community (CCRC) residents. Reliability and validity of the multidimensional construct of resident satisfaction were ensured through confirmatory factor analysis. Hierarchical regression analysis and MANOVA were used to test the hypotheses. A total of 157 completed surveys were received. Analysis showed that two categories of resident satisfaction were statistically distinct. Interpersonal aspects of resident satisfaction (resident involvement, social interaction, and staff care) positively impacted WOM intention more than the tangible aspects (room, home, and meals service). The relationship between tangible resident satisfaction and WOM intention was mediated by interpersonal aspects of resident satisfaction. This study contributes to the literature by (1) examining the mediating effect of interpersonal resident satisfaction between tangible satisfaction and WOM intention in community embedded third places and by (2) exploring the role of non-traditional third places, (i.e., third places nested within residential community settings) as opposed to conventional types (i.e., individual commercial settings). Thus, it addresses the call for research on permanent residents with long-duration service experiences and the effect of one location nested within another.

Whole Person, Whole Journey: Developing a Person-Centred Regional Dementia Strategy

We present the development of a regional dementia strategy in Southwestern Ontario, Canada. We worked with stakeholders in a regional health authority to develop a dementia strategy. We conducted interviews with persons with dementia and their care partners (n = 26) and health care administrators and policy makers (n = 33); and administered a priority-setting survey (n = 64). Both participant groups identified provider compassion, professionalism, and care in the early stages of dementia as system strengths. Both groups also highlighted a need for more integration and coordination, a need for more person-centred care, support for care partners, and more flexibility in the provision and receipt of services. The highest-ranked priorities were improving care partner support, improving access to care, and improving system-wide quality. We integrate these strengths, needs, and priorities in a strategic framework, “Whole Person, Whole Journey”. Organizations developing a dementia strategy may use this framework as a springboard for their own work.

Revisiting the Role of Physicians in Assisted Living and Residential Care Settings

As the United States population ages, a higher share of adults is likely to use long-term services and supports. This change increases physicians' need for information about assisted living and residential care (AL/RC) settings, which provide supportive care and housing to older adults. Unlike skilled nursing facilities, states regulate AL/RC settings through varying licensure requirements enforced by state agencies, resulting in differences in the availability of medical and nursing services. Where some settings provide limited skilled nursing care, in others, residents rely on resident care coordinators, or their own physicians to oversee chronic conditions, medications, and treatments. The following narrative review describes key processes of care where physicians may interact with AL/RC operators, staff, and residents, including care planning, managing Alzheimer's disease and related conditions, medication management, and end-of-life planning. Communication and collaboration between physicians and AL/RC operators are a crucial component of care management.

Assessing Determinants of Perceived Quality in Transitions for People with Dementia: a Prospective Observational Study

Background

The trajectory of dementia through time is characterized by common transitions which are difficult for persons with dementia (PWDs) and their families and friends. Our study sought to identify determinants for the quality of transition outcomes.

Method

A 24-month, prospective, longitudinal design identified specific transitions as they occurred in 108 person-with-dementia/caregiver dyads, and assessed the perceived transition quality from the perspective of the caregiver and what we denote as the 'summative' transition quality outcome variable (as explained in the Data Processing section under Methods).

Results

Among caregivers and during the authors' deliberations of the summative transition quality outcomes, good transition quality was associated with the PWD's baseline Disability Assessment for Dementia (OR 1.04, 95% CI 1.02-1.06 per increase in percent score based on summative assessments), and with the PWD's higher baseline quality of life scores (OR 1.11, 95% CI 1.05-1.18 per increase in unit of score in QOL-AD based on summative assessments). Caregiver-perceived better outcome quality was associated with lower caregiver burden, (OR 0.97, 95% CI 0.95-0.99 per unit CBI score increase).

Conclusion

Identifying determinants of successful transitions is feasible and may be translated into practical guidance for use in clinical encounters. Those with worse prior quality of life or worse performance in activities of daily living appear to require specific support during transitions, as do those whose caregivers report higher levels of burden.

Marital Status and Persons With Dementia in Assisted Living

Despite the prevalence of dementia among residents in assisted living (AL), few researchers have focused on the length of stay (LOS) in AL among this population. Little is known about the factors that may contribute to LOS in these settings, particularly for residents with dementia. In the current study, a sub-set of AL residents with dementia (n = 112) was utilized to examine whether marital status was associated with LOS in AL as this has received sparse attention in previous research despite studies suggesting that marital status influences LOS in other health-care and long-term care settings. The Andersen-Newman behavioral model was used as a conceptual framework for the basis of this study of LOS, marital status, and dementia in AL. We hypothesized that persons with dementia who were married would have longer LOS than unmarried persons with dementia in AL. Cox regression was used to examine the association between marital status and LOS in AL of residents with dementia and whether activities of daily living were related to discharge from AL settings among married and unmarried residents with dementia. Main effects for marital status and the interaction between marital status and mobility with LOS were examined. Study findings provide information related to the psychosocial needs of AL residents with dementia and offer implications for assessing the on-going needs of vulnerable AL residents.

Diagnosis and Disruption: Population-Level Analysis Identifying Points of Care at Which Transitions Are Highest for People with Dementia and Factors That Contribute to Them

OBJECTIVES

To examine transitions that individuals with dementia experience longitudinally and to identify points of care when transitions are highest and the factors that contribute to those transitions.

DESIGN

Population-based 10-year retrospective cohort study from 2000 to 2011.

SETTING

General community.

PARTICIPANTS

All individuals aged 65 and older newly diagnosed with dementia in British Columbia, Canada.

MEASUREMENTS

The frequency and timing of transitions over 10 years, participant characteristics associated with greater number of transitions, and the influence of recommended dementia care and high-quality primary care on number of transitions.

RESULTS

Individuals experience a spike in transitions during the year of diagnosis, driven primarily by hospitalizations, despite accounting for end of life or newly moving to a long-term care facility (LTCF). This occurs regardless of survival time or care location. Regardless of survival time, individuals not in LTCFs experience a marked increase in hospitalizations in the year before and the year of death, often exceeding hospitalizations in the year of diagnosis. Receipt of recommended dementia care and receipt of high-quality primary care were independently associated with fewer transitions across care settings.

CONCLUSION

The spike in transitions in the year of diagnosis highlights a distressing period for individuals with dementia during which unwanted or unnecessary transitions might occur and suggests a useful target for interventions. There is an association between recommended dementia care and outcomes and evidence of the continued value of high-quality primary care in a complex population at a critical point when gaps in continuity are especially likely.

Live-in Care Workers in Sheltered Housing for Older Adults in Israel: The New Sheltered Housing Law

Supportive housing schemes were historically aimed to provide group accommodation for older adults. With the aging of residents, facilities were required to enable them to receive care services in order to allow them to age in place. Thus, different countries and different facilities developed different models of housing with care, reflecting cultural and policy diversities. Despite all of the different models, there are many commonalities among the supportive housing schemes across countries. These include provision of dwelling units and care services provided by either the facility or by external agencies. The aims of this article are threefold: to describe the historical development of the ever-evolving supportive care housing phenomena; to point at variations in models of housing and care within the international context; and to present a new Israeli model that enables residents to privately hire live-in care workers to meet their care needs. This is a unique model in the international context that has not been reported before. The article describes the main ideas of the new model and discusses the challenges that it raises and pinpoints the unresolved issues associated with the presence of live-in care workers employed by residents of sheltered housing that should be addressed.

Stress and Spirituality on the Depressive Symptoms of Older Adults in Assisted Living: Gender Differences

In this study the authors explore the effects of stress and spirituality on the depressive symptoms of 92 older adult men and 224 older adult women who reside in assisted living facilities. Hierarchical regression reveals that stress was related to increases in depressive symptoms. The stress of women was more strongly associated with depressive symptoms than found among men. In contrast, spiritual coping was associated with a decrease in depressive symptoms among all older adults in assisted living. The spiritual coping of older adult women was not a significant predictor of decreased depressive symptoms. Through this study the authors support the use of spiritual interventions to alleviate depressive symptoms experienced by older adults in assisted living.

Social relations and resident health in assisted living: an application of the convoy model

PURPOSE

This article, based on analysis of data from a mixed methods study, builds on a growing body of assisted living (AL) research focusing on the link between residents' social relationships and health. A key aim of this analysis, which uses the social convoy model as a conceptual and methodological framework, was to examine the relative importance of coresident relationships and other network ties to residents' subjective well-being.

DESIGN AND METHODS

We analyzed data from structured face-to-face interviews and social network mapping conducted with 192 AL residents in 9 AL facilities in Georgia.

RESULTS

Having a higher proportion of family ties in one's network was the single most important predictor of well-being, whereas possessing some ties to coresidents and nonfamily members outside AL also had a positive effect. Findings showed that relationships among coresidents generally were important although not emotionally close. Having more close ties was associated with lower well-being, suggesting that not all close ties are beneficial. The majority (84%) of residents' closet ties were with family members.

IMPLICATIONS

Findings illuminate the crucial role families play in residents' overall health and well-being and demonstrate the importance of helping residents develop and maintain a range of network ties, including "weak" ties with coresidents and nonfamily outside AL.

Supporting a Relative’s Move into Long-term Care: Starting Point Shapes Family Members’ Experiences

Cette étude fondée sur la théorie a exploré les expériences des membres de la famille qui soutenaient leurs proches qui sont déplacés dans les foyers de soins de longue durée (FSLD). Chaque étape du processus de transition a été examinée, y compris le rôle du point de départ à façonner l’expérience. Dans les six semaines suivant le déménagement, une vingtaine de membres des familles qui avaient quitté un parent dans un FSLD ont été interviewés. Les résultats ont révelé que le point de départ a eu un effet profond sur les expériences des membres des familles en acceptant la nécessité et le moment où il faut faire le déplacement de leur parent en un FSLD (avant le déménagement), et à croire que le FSLD choisi est un environnement positif pour leur parent (après le déménagement). Les politiques et les processus des FSLD sont aussi importants. Cependant, quand l’acceptation du pré-déménagement a été compromise par des circonstances imputables au point de départ, ces politiques et procédures ont été moins efficaces dans la promotion de l’acceptation de l’après-déménagement. Nous discutons des conditions qui soutient les transitions positives avant, pendant et après le déménagement de chaque point de départ.

Caregiver perspectives on transitions to assisted living and memory care

This study describes family caregivers' experiences moving relatives with Alzheimer's disease or related disorders (ADRD) from their homes to assisted living facilities (ALFs) and subsequently to memory care units (MCUs). We also examined how these experiences differed between caregiver dyad types, such as adult children caring for parents. In-depth interviews with 15 caregivers were transcribed verbatim. Grounded theory identified themes. Constant comparative analysis compared experiences of caregiver dyads. Most caregivers recognized the likely need for future specialized care at the time of the move to the ALF, but did not recall receiving information about transfer policies. The ALF move was harder for spouses, the MCU move for adult children. Assisted living facilities can improve support for caregivers facing a relative's MCU transition through education about advantages of MCU placement and information about transfer policies. Support needs during transitions may differ between adult children and spouses.

Advantage and choice: social relationships and staff assistance in assisted living

OBJECTIVES. To understand how "cumulative inequality" (CI), expressed as individual advantage and choice, and "external social supports" contribute to the quality of social relationships and perceptions of staff assistance for older individuals in different assisted living (AL) settings.

METHODS

Data are from 429 cognitively intact AL residents aged 60 years and older interviewed for the Florida Study of Assisted Living. Bivariate and multivariate statistical analyses show how individual advantage and choice and external social networks influence respondents' social relationships and staff assistance in AL.

RESULTS

Controlling for resident and facility characteristics, being able to pay privately enhances resident satisfaction with staff assistance and having control over the move to AL is positively associated with perceptions of staff relationships and assistance. Maintaining contact with pre-AL friends predicts quality of coresident relationships, as does family contact. Regular contact with family buffers some of the disadvantages associated with CI for perceptions of staff relationships but not perceptions of staff assistance. Discussion. Individual advantage and choice influence the quality of staff relationships and assistance for AL residents but matter little for coresident relationships. External social relationships buffer some of the risks associated with CI for perceptions of staff relationships but not perceived quality of staff assistance. Findings highlight outcomes associated with CI, including predictable risks that disadvantaged elders face in particular types of AL settings, differential advantages others enjoy that influence positive perceptions of staff relationships and staff assistance, and the enduring importance of supportive social relationships.

Dementia and transitioning from assisted living to memory care units: perspectives of administrators in three facility types

PURPOSE

This study examines transitioning residents with Alzheimer's disease or a related disorder (ADRD) from assisted living facilities (ALFs) to memory care units (MCUs) from the perspective of 3 ALF organizational models: freestanding ALFs, ALFs with MCUs, and ALFs in continuing care retirement communities (CCRCs) with MCUs.

DESIGN AND METHODS

In-depth interviews were conducted with 37 ALF administrators, representing the 3 ALF types. Grounded theory identified major themes. Thematic analysis organized content. The constant comparison method compared themes among ALF types.

RESULTS

Administrators in freestanding ALFs were notably more likely to discuss transfer policies on admission. CCRCs with MCUs were more likely to make multidisciplinary decisions. In ALFs with MCUs, typically, the administrator and the director of nursing or resident care coordinator decided. In all ALFs, challenges included family resistance and denial of deficits, although there was notably less resistance in freestanding ALFs. CCRCs were much less likely than ALFs with MCUs to have trial admissions.

IMPLICATIONS

ALF administrators may reduce family resistance to the MCU transfer by maintaining ongoing dialogue with family, discussing transfers at admission, conducting periodic resident reassessments, and providing opportunities for families to learn about ADRD.

An ethnographic study of stigma and ageism in residential care or assisted living

PURPOSE

This study explored aspects of stigmatization for older adults who live in residential care or assisted living (RC-AL) communities and what these settings have done to address stigma.

DESIGN AND METHODS

We used ethnography and other qualitative data-gathering and analytic techniques to gather data from 309 participants (residents, family and staff) from six RC-AL settings in Maryland. We entered the transcript data into Atlas.ti 5.0. We analyzed the data by using grounded theory techniques for emergent themes.

RESULTS

Four themes emerged that relate to stigma in RC-AL: (a) ageism in long-term care; (b) stigma as related to disease and illness; (c) sociocultural aspects of stigma; and (d) RC-AL as a stigmatizing setting. Some strategies used in RC-AL settings to combat stigma include family member advocacy on behalf of stigmatized residents, assertion of resident autonomy, and administrator awareness of potential stigmatization.

IMPLICATIONS

Findings suggest that changes could be made to the structure as well as the process of care delivery to minimize the occurrence of stigma in RC-AL settings. Structural changes include an examination of how best, given the resident case mix, to accommodate care for persons with dementia (e.g., separate units or integrated care); processes of care include staff recognition of resident preferences and strengths, rather than their limitations.

Transitioning dementia residents from assisted living to memory care units: a pilot study

Our study examined the process of transitioning residents of assisted living facilities (ALFs) who have Alzheimer's disease or a related disorder to memory care units (MCUs). In-depth surveys with 10 ALF administrators in South Carolina were conducted. Grounded theory identified major themes; thematic analysis organized content. Most administrators used a preadmission screening process to assess cognitive status. About half reported that they discussed the possibility of future transfer to another level of care with the family at admission. Most administrators said that their facilities had transfer policies in place; of these, only two-thirds discussed their policies with families on admission. Transfer triggers included leaving the facility without anyone's knowledge, disturbing behaviors, and increased care needs. Challenges included family resistance and greater costs of MCUs. Assisted living facilities that were part of continuing care retirement communities used more multidisciplinary transfer decision-making than free-standing ALFs. Suggested improvements stressed educating families about dementia and MCUs.

Efficacy of a geriatrics team intervention for residents in dementia-specific assisted living facilities: effect on unanticipated transitions

OBJECTIVES

To determine whether a multidisciplinary team intervention minimizes unanticipated transitions from assisted living for persons with dementia.

DESIGN

Randomized trial.

SETTING

Two dementia-specific assisted living facilities in Connecticut owned and managed by the same corporation.

PARTICIPANTS

One hundred older adults with dementia who relocated to assisted living.

INTERVENTION

Four systematic multidisciplinary assessments by a geriatrician, geriatrics advanced practice nurse, physical therapist, dietitian, and social worker during the first 9 months of relocation to assisted living.

MEASUREMENTS

Permanent relocation to a nursing facility, emergency department (ED) visits, hospitalization, and death.

RESULTS

Fifty-five residents experienced any unanticipated transition out of assisted living, on average 84 +/- 74 days after relocation; falls were the primary reason for transition. The intervention reduced the risk of any unanticipated transitions (13%), permanent relocation to a nursing facility (11%), ED visits (12%), hospitalization (45%), and death (63%), but the results did not meet statistical significance. In secondary analysis, more men experienced any unanticipated transition (P<.001), hospitalization (P<.001), or death (P<.001) than women.

CONCLUSION

Although an untargeted multidisciplinary intervention did not significantly reduce the risk of transitions for individuals with dementia relocating to assisted living in this small sample, trends for decreasing hospitalization and death were found. The data further suggest that those at risk for falls and men may benefit from targeted clinical interventions to prevent unanticipated transitions, especially during the first 3 months after relocation.

Attitudes, stress, and satisfaction of staff who care for residents with dementia

PURPOSE

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.

DESIGN AND METHODS

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.

RESULTS

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.

IMPLICATIONS

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.