Dementia-Specific Assisted Living: Clinical Factors and Psychotropic Medication Use:

During the past decade, assisted living (AL) has become an increasingly popular alternative for older adults who are unable or unwilling to live independently but wish to avoid nursing home care. The popular notion that AL is housing with supportive services and health care (Assisted Living Federation of America, 2007) but not a level of care within the long-term care continuum (Hyde, 2004) is questionable when the frequency and severity of dementia and other psychiatric disturbances among AL residents is considered. Recent reports indicate that as many as 68% of AL residents have dementia, another 10% have cognitive impairments that are not classifiable as dementia, and 25% have other active psychiatric disturbances such as anxiety and depressive disorders (Rosenblatt et al., 2004). Behavioral and psychological symptoms that occur in 90% of older adults with dementia at some point during the course of their illness (Haupt, Kurz, & Janner, 2000) are reported to occur in more than half of AL residents (Boustani et al., 2005). In tandem, estimates suggest that between 35% and 53% of AL residents take one or more antipsychotic, antidepressant, anxiolytic, and sedative or hypnotic medications (Boustani et al., 2005; Gruber-Baldini, Boustani, Sloane, & Zimmerman, 2004; Lakey, Gray, Sales, Sullivan, & Hedrick, 2006). In many important respects, the care needs of persons with dementia in AL are nearly equivalent to those of persons living in nursing homes, as documented in a series of papers comparing these two long-term care alternatives (Schulz, 2005). Although nursing home care is widely viewed as being over-regulated, lack of regulatory oversight in AL has resulted in wide variations in the type and severity of impairments that are accommodated, in staff preparation and training, and in the range of supportive and personal-care services provided. Of specific relevance here, there are currently no regulations related to the use of psychotropic medications in AL, such as documenting indications for their use, periodic reviews regarding continued need, or efforts to reduce and discontinue unneeded medications (National Center for Assisted Living [NCAL], 2007). These activities, like many other services, are voluntarily provided by some AL residences but are not uniformly conducted. As a result, older adults in AL may be vulnerable to the same psychotropic prescribing practices that were observed in nursing home care before implementation of nursing home reform legislation. The purpose of this article is to describe the level of cognitive impairment, frequency of anxiety and depression symptoms, and use of psychotropic medication among older adults living in dementia-specific AL settings. Findings from this pilot study are compared and contrasted to reports in the literature that describe older adults with dementia in AL but in which the participants' residence is not identified as dementia-specific care units (e.g., older adults with dementia living in “regular” AL along with non-cognitively impaired persons). Implications for psychiatric mental health nurses who may interface with AL staff and residents are reviewed.