Authored by: Kim Warchol, OTR/L

THE PROBLEM

Assisted Living is one of the fastest growing areas of health care as many who are in need of long term care are seeking out the aesthetically pleasing, homelike environment of assisted living versus the institutional skilled nursing environment. There are a number of people who are living in Assisted Living Facilities (ALFs) who have some degree of dementia and too often these residents are not identified or treated appropriately. The Maryland Assisted Living study results stated:

"Two-thirds (67.7%) of participants had dementia diagnosable according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (81% small facilities and 63% large). 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." Source: J Am Geriatr Soc. 2004 Oct;52(10):1618-25. The Maryland Assisted Living Study: prevalence, recognition, and treatment of dementia and other psychiatric disorders in the assisted living population of central Maryland. Rosenblatt, Samus QM, Steele CD, Baker AS, Harper MG, Brandt J, Rabins PV, Lyketsos CG.

The fact is dementia leads to many serious problems. Read below.

"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."
Source: J Am Geriatr Soc. 2007 Jul;55(7):1031-7. Effect of dementia and treatment of dementia on time to discharge from assisted living facilities: the Maryland assisted living study.Lyketsos CG, Samus QM, Baker A, McNabney M, Onyike CU, Mayer LS, Brandt J, Rabins P, Rosenblatt A.

"Approximately one-third (34%) of RC/AL residents exhibited one or more behavioral symptoms at least once a week. 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. More than 50% of RC/AL residents were taking a psychotropic medication."
Source: J Am Geriatr Soc. 2004 Oct;52(10):1610-7. Behavioral symptoms in residential care/assisted living facilities: prevalence, risk factors, and medication management. Gruber-Baldini AL, Boustani M, Sloane PD, Zimmerman S.

"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."
Source: Int J Geriatr Psychiatry. 2000 Jul;15(7):586-93. Characteristics and outcomes of dementia residents in an assisted living facility. Kopetz S, Steele CD, Brandt J, Baker A, Kronberg M, Galik E, Steinberg M, Warren A, Lyketsos CG.

THE SOLUTIONS

These study results and my own experience and observations seem to indicate an environment that is often ill-prepared to care for this population majority. I believe the root of the care management problem is in the resident admission and ongoing assessment process. 

In many ALFs the resident assessment performed by the facility is very lean and is often more like a questionnaire of needs versus a professional assessment of needs. A physician assessment is usually performed prior to admission but often this does not adequately identify the cognitive status and the specific associated functional limitations of the client. Many people move to an ALF in Allen level 4 and we know that in Allen level 4 persons will have IADL and then ADL needs however we also know these individuals are not good self-reporters of needs.

In my experience, the facility may have half of its residents performing in Allen level 4 and this is the level in which I have witnessed the greatest discrepancy in what is delivered versus what is actually needed. We know the problem is associated with the often relatively intact verbal skills fooling the assessor. It will then take time for the facility to realize that Mrs. Smith is having some problems and by then the problems may have led to a serious issue such as a fall or depression leading to hospitalization.

The key for success is rooted in enhancing the facility assessment process. This should be done in two ways:

• Improved resident assessment performed by the facility: The facility must identify a team member within the environment who can perform a comprehensive evaluation of needs. This evaluation is usually performed by the Director of Nursing or other lead nurse. The evaluation should include a cognitive assessment such as the FAST, GDS and/or MMSE. In addition, the assessment should look at other areas that impact function such as physical limitations and sensory loss. The assessor will then make a determination of the level of assist the client may require. This will help to eliminate the "getting to know you/trial and error process" that typically ensues after admission.
• A professional therapy assessment: Many ALFs use home health as the only source of therapy involvement. Most often the delivery of service involves coming in AFTER the resident has had a medical issue and/or hospitalization. This doesn't solve our need for a proactive therapy assessment to help identify the care needs and necessary approaches for a complex client. I recommend an ALF partner with a therapy organization who can bill Medicare Part B and is trained in the Allen theory. We suggest the therapy team be on sight 5 days per week and truly become a part of the ALF team. When a resident is admitted who has an Alzheimer's or related dementia diagnosis, the therapist can perform an evaluation, including the Allen cognitive assessment, identify best ability to function, and create a plan to maximize and maintain function and safety.

Another essential element for success is dementia training for all facility staff. Over 30 states in the U.S. now require some amount of specialized dementia training for facility staff of an ALF who markets caring for persons with dementia. I believe it is absolutely essential that staff are prepared with a quality dementia training program to help them to understand the complexities of the disease and approaches that work.

SUMMARY

In my opinion, many ALFs do not know the complexity of the clients that they are serving. Many are oblivious to the pervasiveness of dementia and the relationship of dementia to poor outcomes and high liability. This is a golden environment for therapists to be a part of as we infuse a high degree of sophisticated medical and dementia assessment/care knowledge that will help the residents and the facility to succeed. I believe ALFs can be a wonderful alternative to a SNF or to remaining at home. However, these environments must begin to provide the expertise needed to serve persons with dementia.

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