Care of Dementia and Other Mental Disorders in Assisted Living Facilities: New Research and Borrowed Knowledge

Research on assisted living facilities (ALFs) has demonstrated that their residents overlap considerably with those receiving long-term care in nursing homes (NHs) in terms of their ages, cognitive status, chronic medical illnesses, disability, and care needs. Based on these findings, studies conducted specifically in these facilities and lessons learned from research and experience in NHs should inform policies and practice in ALFs. Two articles in this issue of the Journal demonstrate high levels of dementia, other psychiatric disorders, and behavioral disturbance in ALFs, similar to the rates reported for NHs. Together, the articles provide compelling evidence that mental health (MH) care is an important component of the services that should be provided in these facilities, but interpreting and applying their findings requires integrating them with knowledge about the care of NH residents with these conditions. The article by Rosenblatt et al. reports findings from the Maryland Assisted Living Study, a National Institute of Mental Health–supported study based on structured clinical interviews of a representative sample of residents, families, and staff from a stratified sample of small and large ALFs in central Maryland. It reports that approximately two-thirds of the residents had a diagnosable dementia, and 70% of these had clinically significant psychiatric symptoms. Furthermore, more than one-quarter of the residents had another diagnosable psychiatric disorder. Approximately 70% of the residents had depression; 13% had an anxiety disorder, and 12% had a psychosis. Altogether, 80% of the residents had dementia or an active psychiatric disorder. The article proposes a broad view of what constitutes appropriate treatment for dementia, stating, ‘‘Treatment did not necessarily imply pharmacological or medical treatment. For example a participant with Alzheimer’s disease, whose condition was recognized by the facility staff, who was receiving appropriate supervision, and who had a behavioral plan in place to prevent falls or other accidents, might have been regarded as fully treated for dementia. ’’ They do not discuss activities or sensitivity to cognitive impairment in the manner in which moment-to-moment or day-to-day care is provided as components of treatment. Nevertheless, using this approach, they judged that approximately 50% of residents with dementia were receiving complete treatment. The article by Gruber-Baldini et al. reports on the Collaborative Studies of Long-term Care, a National Institute on Aging–supported study that obtained caregiver reports of behavioral symptoms in a random sample of residents from ALFs in Florida, Maryland, New Jersey, and North Carolina. It reported that approximately 50% of residents had dementia or cognitive impairment, 14% had depression, and 13% had a psychosis. Altogether, two-thirds had dementia, depression, psychosis, or another psychiatric disorder. The major findings were that approximately onethird of the residents exhibited a behavioral symptom at least once during the 2 weeks before the assessment. Twelve percent of the sample exhibited aggression, with the most common symptoms in this category being cursing and verbal aggression; 22% exhibited verbal behavioral symptoms, with the most common symptoms being constant requests for attention or help; 21% exhibited physical nonaggressive behavioral symptoms, with the most common being pacing, aimless wandering, and trying to get to a different place; and 12% of residents were reported to exhibit resistance to care. They found that behavioral symptoms were more frequent in residents with cognitive impairment, depression, psychosis, and other psychiatric disorders; those taking psychotropic medications; and those with functional impairment. Fifty-three percent of residents were taking a psychotropic medication, 21% were taking neuroleptics, 33% were taking antidepressants, and 24% were taking anxiolytics or hypnotics. Fifty-nine percent of residents taking psychotropic medications did not have current behavioral symptoms; according to the authors, this could represent either appropriate care or inappropriately high medication use. Thirty-six percent of those with behavioral symptoms were not receiving medication; again, according to the authors, this might represent insufficient assessment and treatment. In their discussion, the authors borrow from the recent consensus recommendations from the American Geriatrics Society and the American Association of Geriatric Psychiatry on Improving the Quality of Mental Health in U.S. NHs to recommend interdisciplinary assessment and treatment of behavioral symptoms and greater use of nonpharmacological interventions. The recommendation for nonpharmacological approaches includes the parenthetical qualification ‘‘especially if medications are not effective. ’’ The two articles together provide compelling evidence that MH care is a necessary part of assisted living. In this, they extend previous findings on the similarity of ALF and NH residents. The implication must be that dementia and other psychiatric disorders are common causes, components, complications, or comorbidities of the disabilities that make long-term care necessary, regardless of whether services are delivered in ALFs, NHs, or other settings. The