Center for Excellence in Assisted Living CEAL@UNC

Advancing the well-being of the people who live and work in assisted living through research, practice, and policy.

Journal of Applied Gerontology

Bioethics in Gerontology: Developing a Typology of Ethical Issues in Assisted Living

May 1, 2024
Assisted living (AL) simultaneously is home to older adults who cannot live independently and a place where people work and visit and, therefore, where value conflicts are apt to arise. In this report we present the “Typology of Ethical Issues in Assisted Living” with emphasis on its development. The typology derives from a synthesis of […]

Bioethics in Gerontology: Developing a Typology of Ethical Issues in Assisted Living

by Lea Efird-Green

Assisted living (AL) simultaneously is home to older adults who cannot live independently and a place where people work and visit and, therefore, where value conflicts are apt to arise. In this report we present the “Typology of Ethical Issues in Assisted Living” with emphasis on its development. The typology derives from a synthesis of […]

Objectively Measured Physical Activity and Sedentary Behaviors Among Older Adults in Assisted Living Facilities: A Scoping Review

Apr 1, 2024
Older adults in assisted living facilities (ALF) are at risk for low physical activity (PA) and high sedentary behavior (SB), both of which place them at risk for negative health outcomes. The purpose of this scoping review was to synthesize evidence describing the volume of device-measured PA/SB, factors associated with PA/SB, and interventions designed to […]

Objectively Measured Physical Activity and Sedentary Behaviors Among Older Adults in Assisted Living Facilities: A Scoping Review

by Lea Efird-Green

Older adults in assisted living facilities (ALF) are at risk for low physical activity (PA) and high sedentary behavior (SB), both of which place them at risk for negative health outcomes. The purpose of this scoping review was to synthesize evidence describing the volume of device-measured PA/SB, factors associated with PA/SB, and interventions designed to […]

Home Time and State Regulations Among Medicare Beneficiaries in Assisted Living Communities

Dec 1, 2023
WHAT THIS MEANS FOR YOU: A study of “home time" (days alive and not in healthcare institutions such as hospitals or skilled nursing facilities) of over 59,000 Medicare beneficiaries who transitioned into assisted living in 2018 found that residents spent 94% of their first year at home in the community. Characteristics associated with lower home time included dual Medicare-Medicaid eligibility, having more chronic conditions, and specific conditions (e.g., dementia). Additionally, in states with more specific regulations for direct care worker staffing and training, and lower specificity for staff licensing requirements, residents tended to spend more time at home. Thus, both individual characteristics and state regulations may impact home time for new assisted living residents.

Home Time and State Regulations Among Medicare Beneficiaries in Assisted Living Communities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A study of “home time” (days alive and not in healthcare institutions such as hospitals or skilled nursing facilities) of over 59,000 Medicare beneficiaries who transitioned into assisted living in 2018 found that residents spent 94% of their first year at home in the community. Characteristics associated with lower home time included dual Medicare-Medicaid eligibility, having more chronic conditions, and specific conditions (e.g., dementia). Additionally, in states with more specific regulations for direct care worker staffing and training, and lower specificity for staff licensing requirements, residents tended to spend more time at home. Thus, both individual characteristics and state regulations may impact home time for new assisted living residents.

Paperwork, Paradox, and PRN: Psychotropic Medication Deficiencies in Assisted Living

Jun 1, 2023
WHAT THIS MEANS FOR YOU: This study analyzed 170 psychotropic medication deficiency citations from 152 Oregon assisted living communities to determine discrepancies in state licensing and oversight of psychotropic medication use. It found most deficiencies involved documentation errors; there were unclear regulations for direct care workers who distribute medications; and there was a persistent disconnect about when to seek expertise before requesting psychotropic use.

Paperwork, Paradox, and PRN: Psychotropic Medication Deficiencies in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study analyzed 170 psychotropic medication deficiency citations from 152 Oregon assisted living communities to determine discrepancies in state licensing and oversight of psychotropic medication use. It found most deficiencies involved documentation errors; there were unclear regulations for direct care workers who distribute medications; and there was a persistent disconnect about when to seek expertise before requesting psychotropic use.

Depression within the First Year of Relocation to Residential Care/Assisted Living: Where You Come From Matters

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Data from a national survey of 2,651 assisted living residents found that approximately 35% moved to assisted living from an acute/post-acute facility; they were more likely to have depression compared to those moving from community-based residences.

Depression within the First Year of Relocation to Residential Care/Assisted Living: Where You Come From Matters

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Data from a national survey of 2,651 assisted living residents found that approximately 35% moved to assisted living from an acute/post-acute facility; they were more likely to have depression compared to those moving from community-based residences.

Ethics of Health Information Sharing and Social Relationships at End of Life in Assisted Living

Apr 1, 2022
WHAT THIS MEANS FOR YOU: This qualitative study of observation and 61 interviews with assisted living residents, family members, staff, and external care workers in one large community in Atlanta, found that while sharing health information could strengthen social bonds among residents, there were concerns about privacy; for example, when inappropriate public exchanges occurred, they hindered social relationship building. Barriers to communicating health information contributed to resident isolation, but negotiating privacy boundaries to share such information may promote resident wellbeing.

Ethics of Health Information Sharing and Social Relationships at End of Life in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This qualitative study of observation and 61 interviews with assisted living residents, family members, staff, and external care workers in one large community in Atlanta, found that while sharing health information could strengthen social bonds among residents, there were concerns about privacy; for example, when inappropriate public exchanges occurred, they hindered social relationship building. Barriers to communicating health information contributed to resident isolation, but negotiating privacy boundaries to share such information may promote resident wellbeing.

The Ethics in Long-Term Care Model: Everyday Ethics and the Unseen Moral Landscape of Assisted Living

Apr 1, 2022
WHAT THIS MEANS FOR YOU: Drawing from existing research, theories, and case examples, this article highlighted moral complexities experienced in assisted living (e.g., privacy, sexual intimacy, safety and risk) and proposed a framework to identify and address these issues and promote more ethically sound practices. The proposed model centers on moral decision-making and interpersonal encounters and is intended to guide future research, policy, and practice.

The Ethics in Long-Term Care Model: Everyday Ethics and the Unseen Moral Landscape of Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Drawing from existing research, theories, and case examples, this article highlighted moral complexities experienced in assisted living (e.g., privacy, sexual intimacy, safety and risk) and proposed a framework to identify and address these issues and promote more ethically sound practices. The proposed model centers on moral decision-making and interpersonal encounters and is intended to guide future research, policy, and practice.

Potential Side Effects and Adverse Events of Antipsychotic Use for Residents With Dementia in Assisted Living: Implications for Prescribers, Staff, and Families

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study examined the use of antipsychotic medications among residents with dementia in 91 AL communities across seven states. The prevalence of potential side effects was high (93%) and of possible adverse events low, (6%), potentially associated with medication side effects. Quetiapine (Seroquel) and risperidone (Risperdal) were the most frequently prescribed antipsychotics. Most, but not all, residents’ family members were aware of their relative’s antipsychotic use.

Potential Side Effects and Adverse Events of Antipsychotic Use for Residents With Dementia in Assisted Living: Implications for Prescribers, Staff, and Families

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined the use of antipsychotic medications among residents with dementia in 91 AL communities across seven states. The prevalence of potential side effects was high (93%) and of possible adverse events low, (6%), potentially associated with medication side effects. Quetiapine (Seroquel) and risperidone (Risperdal) were the most frequently prescribed antipsychotics. Most, but not all, residents’ family members were aware of their relative’s antipsychotic use.

Assisted Living Administrators’ Approaches to Advance Care Planning

Feb 1, 2022
WHAT THIS MEANS FOR YOU: Interviews with 27 AL administrators revealed different approaches to advanced care planning (ACP). They all acknowledged the importance of ACP and often discussed topics like “do-not-resuscitate” orders when new residents arrived. Challenges included insufficient ACP training for staff and administrators and some reluctance from residents and families to discuss ACP. Most communities lacked a systematic, structured ACP approach.

Assisted Living Administrators’ Approaches to Advance Care Planning

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Interviews with 27 AL administrators revealed different approaches to advanced care planning (ACP). They all acknowledged the importance of ACP and often discussed topics like “do-not-resuscitate” orders when new residents arrived. Challenges included insufficient ACP training for staff and administrators and some reluctance from residents and families to discuss ACP. Most communities lacked a systematic, structured ACP approach.

Model Testing of the Factors that Influence Performance of Function Focused Care and Function among Assisted Living Residents

Feb 1, 2022
WHAT THIS MEANS FOR YOU: A study of 550 AL residents from 59 communities found that factors such as better physical and cognitive health, positive care interactions, and supportive environments were associated with increased participation in function-focused care. Additionally, for-profit communities had higher levels of function-focused care despite having residents with lower functioning.

Model Testing of the Factors that Influence Performance of Function Focused Care and Function among Assisted Living Residents

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A study of 550 AL residents from 59 communities found that factors such as better physical and cognitive health, positive care interactions, and supportive environments were associated with increased participation in function-focused care. Additionally, for-profit communities had higher levels of function-focused care despite having residents with lower functioning.