2025 CEAL@UNC Research Award Summary
Mental Health
Prevalence of Suicidal Behaviors in Residents of Long-Term Care Facilities: A Systematic Review and Meta-Analysis
This systematic review of 20 studies examined the prevalence of suicidal behaviors of long-term care residents. The prevalence of worldwide suicidal behavior was just over 6%, putting residents at higher risk than the general population. Physical health and psychological concerns were related to suicide risk, suggesting areas for potential prevention strategies.
Prevalence of Suicidal Behaviors in Residents of Long-Term Care Facilities: A Systematic Review and Meta-Analysis
This systematic review of 20 studies examined the prevalence of suicidal behaviors of long-term care residents. The prevalence of worldwide suicidal behavior was just over 6%, putting residents at higher risk than the general population. Physical health and psychological concerns were related to suicide risk, suggesting areas for potential prevention strategies.
Resonances of Feeling Alone: A Systematic Review Unveiling Older Persons’ Loneliness and Its Mechanisms in Residential Care Facilities
This systematic review of 16 articles assessed long-term care (LTC) community residents' experiences of loneliness and the mechanisms underlying those experiences. Three themes emerged, leading to the development of a conceptual model of loneliness: relational and individual loneliness, perception and emotional distress, and the impact of context and cognitive processes. Perceptions of reduced social control and connections exacerbate loneliness. Developing supportive social environments within LTC communities was identified as a key factor in addressing resident loneliness general quality of life.
Resonances of Feeling Alone: A Systematic Review Unveiling Older Persons’ Loneliness and Its Mechanisms in Residential Care Facilities
This systematic review of 16 articles assessed long-term care (LTC) community residents’ experiences of loneliness and the mechanisms underlying those experiences. Three themes emerged, leading to the development of a conceptual model of loneliness: relational and individual loneliness, perception and emotional distress, and the impact of context and cognitive processes. Perceptions of reduced social control and connections exacerbate loneliness. Developing supportive social environments within LTC communities was identified as a key factor in addressing resident loneliness general quality of life.
Dialectical Behavioral Therapy Skills Training in Assisted Living: Transdiagnostic Effects on Goal Attainment, Self-Efficacy, and Symptom Severity
This Austrian study of 52 residents from 4 AL communities examined an 8-week dialectical behavioral therapy skills training intervention's effects on residents' self-efficacy, goal attainment, and psychological distress. Goal attainment and psychological distress scores showed initial improvement, but they were not statistically significant and did not further improve at follow-up, meaning that the intervention may need to be better adapted to the AL setting to be effective.
Dialectical Behavioral Therapy Skills Training in Assisted Living: Transdiagnostic Effects on Goal Attainment, Self-Efficacy, and Symptom Severity
This Austrian study of 52 residents from 4 AL communities examined an 8-week dialectical behavioral therapy skills training intervention’s effects on residents’ self-efficacy, goal attainment, and psychological distress. Goal attainment and psychological distress scores showed initial improvement, but they were not statistically significant and did not further improve at follow-up, meaning that the intervention may need to be better adapted to the AL setting to be effective.
Happy by Nature: Nature Connection as a Source of Psychological Well-Being in Assisted Living Facilities
This study of over 850 residents in 25 Finnish AL communities examined whether connection with nature is associated with psychological well-being and mobility. A higher nature connection score was associated with higher psychological well-being, especially for residents with poor mobility. Other findings revealed residents experience nature in different ways, and that customized access to the outdoors is a framework for the development of nature-based interventions.
Happy by Nature: Nature Connection as a Source of Psychological Well-Being in Assisted Living Facilities
This study of over 850 residents in 25 Finnish AL communities examined whether connection with nature is associated with psychological well-being and mobility. A higher nature connection score was associated with higher psychological well-being, especially for residents with poor mobility. Other findings revealed residents experience nature in different ways, and that customized access to the outdoors is a framework for the development of nature-based interventions.
Anxiety Among Workers in Institutions for Older Adults During the COVID-19 Pandemic
This study examined questionnaires from 900 nursing home and AL workers in Puerto Rico to understand the factors that contributed to anxiety during the COVID-19 pandemic. Factors such as avoidance, emotional exhaustion, stress, and negative mood were major contributors to feelings of anxiety. The findings highlight the need for mental health support and interventions for long-term care workers both during and after crises to lessen feelings of anxiety and to prevent long-term impacts on well-being.
Anxiety Among Workers in Institutions for Older Adults During the COVID-19 Pandemic
This study examined questionnaires from 900 nursing home and AL workers in Puerto Rico to understand the factors that contributed to anxiety during the COVID-19 pandemic. Factors such as avoidance, emotional exhaustion, stress, and negative mood were major contributors to feelings of anxiety. The findings highlight the need for mental health support and interventions for long-term care workers both during and after crises to lessen feelings of anxiety and to prevent long-term impacts on well-being.
Psychometric Evaluation of the Nursing Homes Short Depression Inventory (NH-SDI) Across Long-Term Care Facilities in Lebanon
This study aimed to test the validity and reliability of the Arabic version of the Nursing Homes Short Depression Inventory (NH-SDI) in 21 Lebanese long-term care communities. Using data from 245 residents, the NH-SDI was determined to be reliable and valid for detecting depressive symptoms among elderly residents, suggesting communities in other Arabic-speaking countries may benefit from using the NH-SDI (Arabic version).
Psychometric Evaluation of the Nursing Homes Short Depression Inventory (NH-SDI) Across Long-Term Care Facilities in Lebanon
This study aimed to test the validity and reliability of the Arabic version of the Nursing Homes Short Depression Inventory (NH-SDI) in 21 Lebanese long-term care communities. Using data from 245 residents, the NH-SDI was determined to be reliable and valid for detecting depressive symptoms among elderly residents, suggesting communities in other Arabic-speaking countries may benefit from using the NH-SDI (Arabic version).
Two New Positive Psychosocial Measures for Persons Living with Dementia
WHAT THIS MEANS FOR YOU: Two pilot studies created and tested two new instruments for evaluating wellbeing for people living with dementia, the Living Well Inventory for Dementia (LWI-D) and the Quality of Day Scale (QODS). Seventeen individuals with early-stage dementia tested the LWI-D, and 30 care dyads tested the QODS. Both measures were supported for acceptability and feasibility, with initial support for reliability and validity; further testing of the instruments is recommended.
Two New Positive Psychosocial Measures for Persons Living with Dementia
WHAT THIS MEANS FOR YOU: Two pilot studies created and tested two new instruments for evaluating wellbeing for people living with dementia, the Living Well Inventory for Dementia (LWI-D) and the Quality of Day Scale (QODS). Seventeen individuals with early-stage dementia tested the LWI-D, and 30 care dyads tested the QODS. Both measures were supported for acceptability and feasibility, with initial support for reliability and validity; further testing of the instruments is recommended.
Considerations for Use of the Cornell Scale for Depression in Dementia Among Assisted Living Residents: Factor Analysis Results
WHAT THIS MEANS FOR YOU: This study tested the Cornell Scale for Depression in Dementia (CSDD) with 511 residents from 85 assisted living (AL) communities in three states to understand if it is an appropriate scale for assessing depression in AL residents. Measure-related analysis led to three items being removed from the scale and a five-factor model showed a better fit than the four-factor model, although both showed poor fit. Although a modified CSDD is partially supported for use with this population, future research should explore more appropriate measures for measuring depression in AL residents.
Considerations for Use of the Cornell Scale for Depression in Dementia Among Assisted Living Residents: Factor Analysis Results
WHAT THIS MEANS FOR YOU: This study tested the Cornell Scale for Depression in Dementia (CSDD) with 511 residents from 85 assisted living (AL) communities in three states to understand if it is an appropriate scale for assessing depression in AL residents. Measure-related analysis led to three items being removed from the scale and a five-factor model showed a better fit than the four-factor model, although both showed poor fit. Although a modified CSDD is partially supported for use with this population, future research should explore more appropriate measures for measuring depression in AL residents.
Stress-Related Coping and its Relationship to Well-Being in Nursing Assistants and Personal Care Aides in Nursing Homes and Assisted Living
WHAT THIS MEANS FOR YOU: This cross-sectional study used questionnaire data from 391 professional caregivers from 13 facilities in 3 states to examine coping and its relationship with demographic characteristics of direct caregivers in long-term care. Older staff used adaptive psychological strategies more than younger staff, and traditionally minoritized staff used more adaptive and less maladaptive psychological strategies than white staff. Using avoidance and maladaptive coping strategies was associated with depressive and anxiety symptoms, as well as burnout. Professional caregivers use a variety of coping mechanisms, and training on adaptive coping could improve outcomes for this population.
Stress-Related Coping and its Relationship to Well-Being in Nursing Assistants and Personal Care Aides in Nursing Homes and Assisted Living
WHAT THIS MEANS FOR YOU: This cross-sectional study used questionnaire data from 391 professional caregivers from 13 facilities in 3 states to examine coping and its relationship with demographic characteristics of direct caregivers in long-term care. Older staff used adaptive psychological strategies more than younger staff, and traditionally minoritized staff used more adaptive and less maladaptive psychological strategies than white staff. Using avoidance and maladaptive coping strategies was associated with depressive and anxiety symptoms, as well as burnout. Professional caregivers use a variety of coping mechanisms, and training on adaptive coping could improve outcomes for this population.
The Role of Workday Characteristics on Perceived Stress and Time Pressure among Nurses in Finnish Long-Term Care – A Cross-Sectional Study
WHAT THIS MEANS FOR YOU: This study examined 503 nurses from 44 AL communities in Finland to examine the relationship between workday characteristics and perceived stress and time pressure. More care task events, clients with greater needs, reduced break times, and disruptions during the day were related to stress and time pressure for staff. Findings indicate that dividing workload evenly among nursing teams can help reduce stress and time pressure.
The Role of Workday Characteristics on Perceived Stress and Time Pressure among Nurses in Finnish Long-Term Care – A Cross-Sectional Study
WHAT THIS MEANS FOR YOU: This study examined 503 nurses from 44 AL communities in Finland to examine the relationship between workday characteristics and perceived stress and time pressure. More care task events, clients with greater needs, reduced break times, and disruptions during the day were related to stress and time pressure for staff. Findings indicate that dividing workload evenly among nursing teams can help reduce stress and time pressure.
A New Measure of Professional Caregiver Coping in Long-Term Care: The LTC COPE
WHAT THIS MEANS FOR YOU: This study developed a new measure for how professional caregivers cope with stress. Data was collected from 391 caregivers in 13 long-term care communities across 3 states using the Long-Term Care Cope instrument. Coping strategies were found to be highly individual with many reporting using multiple strategies. Further testing of the scale is needed to understand and narrow the items in the subcomponents.
A New Measure of Professional Caregiver Coping in Long-Term Care: The LTC COPE
WHAT THIS MEANS FOR YOU: This study developed a new measure for how professional caregivers cope with stress. Data was collected from 391 caregivers in 13 long-term care communities across 3 states using the Long-Term Care Cope instrument. Coping strategies were found to be highly individual with many reporting using multiple strategies. Further testing of the scale is needed to understand and narrow the items in the subcomponents.
Progress of Rehabilitation in Assisted Living for Mentally Ill According to STAX-SA Taxonomy
WHAT THIS MEANS FOR YOU: This study used longitudinal data from a 2020-22 Finnish study of 340 health records of AL residents with mental illness to examine how residents moved through the AL supportive and health services system. Of the residents, 19% progressed to AL communities with fewer services, 79% remained stable, and 2% regressed into AL communities with more services. This means that rehabilitation may not be effectively implemented for these residents and needs to be improved.
Progress of Rehabilitation in Assisted Living for Mentally Ill According to STAX-SA Taxonomy
WHAT THIS MEANS FOR YOU: This study used longitudinal data from a 2020-22 Finnish study of 340 health records of AL residents with mental illness to examine how residents moved through the AL supportive and health services system. Of the residents, 19% progressed to AL communities with fewer services, 79% remained stable, and 2% regressed into AL communities with more services. This means that rehabilitation may not be effectively implemented for these residents and needs to be improved.
Effects of a Meaning in Life Enhancement Program on Depression among Older Adult Residents of Assisted Living Facilities
WHAT THIS MEANS FOR YOU: This quasi-experimental study of 60 older adults in 2 AL communities in Thailand examined the effects of a program to enhance meaning in life and reduce depression. The group that experienced the program, as opposed to routine nursing care, exhibited statistically lower depression scores from baseline and compared to the control group, which means the program may be effective; however, further testing is necessary.
Effects of a Meaning in Life Enhancement Program on Depression among Older Adult Residents of Assisted Living Facilities
WHAT THIS MEANS FOR YOU: This quasi-experimental study of 60 older adults in 2 AL communities in Thailand examined the effects of a program to enhance meaning in life and reduce depression. The group that experienced the program, as opposed to routine nursing care, exhibited statistically lower depression scores from baseline and compared to the control group, which means the program may be effective; however, further testing is necessary.
The Prevalence and Benefits of Self-Compassion Among Professional Caregivers
WHAT THIS MEANS FOR YOU: This cross-sectional study examined the relationship between self-compassion, anxiety and depressive symptoms, and job satisfaction from 391 caregivers across 13 nursing homes and assisted living communities in 3 states. Older caregivers, those with higher education, and those who were born outside the US reported highest self-compassion, while white caregivers reported the lowest. Self-compassion was negatively associated with mental health symptoms and positively associated with job satisfaction, meaning that its use could be beneficial as one method to address workforce issues in long-term care.
The Prevalence and Benefits of Self-Compassion Among Professional Caregivers
WHAT THIS MEANS FOR YOU: This cross-sectional study examined the relationship between self-compassion, anxiety and depressive symptoms, and job satisfaction from 391 caregivers across 13 nursing homes and assisted living communities in 3 states. Older caregivers, those with higher education, and those who were born outside the US reported highest self-compassion, while white caregivers reported the lowest. Self-compassion was negatively associated with mental health symptoms and positively associated with job satisfaction, meaning that its use could be beneficial as one method to address workforce issues in long-term care.
Be Well in AL Recommendations: Resident/Family Checklist
CEAL@UNC recognizes the benefit of ongoing quality improvement in assisted living, including through the implementation of consensus medical and mental health care recommendations disseminated through the Be Well in AL Initiative. This checklist, to be used by residents and their families considering or residing in assisted living, is a helpful tool to understand recommended care […]
Be Well in AL Recommendations: Resident/Family Checklist
CEAL@UNC recognizes the benefit of ongoing quality improvement in assisted living, including through the implementation of consensus medical and mental health care recommendations disseminated through the Be Well in AL Initiative. This checklist, to be used by residents and their families considering or residing in assisted living, is a helpful tool to understand recommended care […]
Estimated Prevalence of Resident-to-Resident Aggression in Assisted Living
WHAT THIS MEANS FOR YOU: Observational data from 930 participants in a cross-sectional study over a 1-month period assessed resident-to-resident aggression in 14 New York AL communities. Approximately 15% of residents were found to have engaged in resident-to-resident aggression, with the two most common types being verbal and physical aggression. Intervention research on the prevention of resident-to-resident aggression is recommended to address its prevalence and negative impacts on residents’ physical and psychological health.
Estimated Prevalence of Resident-to-Resident Aggression in Assisted Living
WHAT THIS MEANS FOR YOU: Observational data from 930 participants in a cross-sectional study over a 1-month period assessed resident-to-resident aggression in 14 New York AL communities. Approximately 15% of residents were found to have engaged in resident-to-resident aggression, with the two most common types being verbal and physical aggression. Intervention research on the prevention of resident-to-resident aggression is recommended to address its prevalence and negative impacts on residents’ physical and psychological health.
Serious Mental Illness in Assisted Living Communities: Association with Nursing Home Placement
WHAT THIS MEANS FOR YOU: An analysis of data from over 289,000 Medicare beneficiaries in 17,265 ALs from 2018 to 2019 revealed that over half of AL residents had at least one serious mental illness diagnosis, with major depression being the most common (93%). Residents with schizophrenia or bipolar disorder were statistically significantly less likely to be permanently placed in NHs (as opposed to continued AL residency) respective to the average rate of placement for all residents in the analysis. However, the risk of permanent NH placement was higher for residents with ADRD, including residents with a schizophrenia or bipolar disorder diagnosis.
Serious Mental Illness in Assisted Living Communities: Association with Nursing Home Placement
WHAT THIS MEANS FOR YOU: An analysis of data from over 289,000 Medicare beneficiaries in 17,265 ALs from 2018 to 2019 revealed that over half of AL residents had at least one serious mental illness diagnosis, with major depression being the most common (93%). Residents with schizophrenia or bipolar disorder were statistically significantly less likely to be permanently placed in NHs (as opposed to continued AL residency) respective to the average rate of placement for all residents in the analysis. However, the risk of permanent NH placement was higher for residents with ADRD, including residents with a schizophrenia or bipolar disorder diagnosis.
Assisted Living Residents with Dementia: Disparities in Mental Health Services Pre and During COVID-19
WHAT THIS MEANS FOR YOU: The in-person and telehealth mental health visits of over 102,000 Medicare beneficiaries living with ADRD in 13,400 AL communities were analyzed using CMS data from 2019 and 2020. Use of these services is low in this population, but it was found that Black residents and those with dual Medicare/Medicaid eligibility were significantly less likely to use these services pre-, and during, the COVID-19 pandemic; however, there were no significant differences in visits via telemedicine (vs. in-person) for any racial or ethnic group or dual eligibles.
Assisted Living Residents with Dementia: Disparities in Mental Health Services Pre and During COVID-19
WHAT THIS MEANS FOR YOU: The in-person and telehealth mental health visits of over 102,000 Medicare beneficiaries living with ADRD in 13,400 AL communities were analyzed using CMS data from 2019 and 2020. Use of these services is low in this population, but it was found that Black residents and those with dual Medicare/Medicaid eligibility were significantly less likely to use these services pre-, and during, the COVID-19 pandemic; however, there were no significant differences in visits via telemedicine (vs. in-person) for any racial or ethnic group or dual eligibles.
Examining Pain, Function, Behavioral Symptoms and Associations with Engagement in Meaningful Activity for Residents with Dementia in Assisted Living
WHAT THIS MEANS FOR YOU: In a study of 71 residents with dementia from 5 AL facilities, pain was linked to lower engagement in meaningful activities (i.e., activities that provide meaning and value to the person based on their individual interests and preferences), even when controlling for age, gender, health conditions, and cognitive capacity.
Examining Pain, Function, Behavioral Symptoms and Associations with Engagement in Meaningful Activity for Residents with Dementia in Assisted Living
WHAT THIS MEANS FOR YOU: In a study of 71 residents with dementia from 5 AL facilities, pain was linked to lower engagement in meaningful activities (i.e., activities that provide meaning and value to the person based on their individual interests and preferences), even when controlling for age, gender, health conditions, and cognitive capacity.
Effect of Immersive Virtual Reality Reminiscence versus Traditional Reminiscence Therapy on Cognitive Function and Psychological Well-being among Older Adults in Assisted Living Facilities: A Randomized Controlled Trial
WHAT THIS MEANS FOR YOU: A study of 60 assisted living residents observed the effects of virtual reality reminiscence and traditional reminiscence therapy on residents’ cognitive function and psychological wellbeing. Compared to a control group, there was a statistically significant increase in cognition and psychological wellbeing in both the reminiscence groups.
Effect of Immersive Virtual Reality Reminiscence versus Traditional Reminiscence Therapy on Cognitive Function and Psychological Well-being among Older Adults in Assisted Living Facilities: A Randomized Controlled Trial
WHAT THIS MEANS FOR YOU: A study of 60 assisted living residents observed the effects of virtual reality reminiscence and traditional reminiscence therapy on residents’ cognitive function and psychological wellbeing. Compared to a control group, there was a statistically significant increase in cognition and psychological wellbeing in both the reminiscence groups.
The Complexity of Providing Behavioral Healthcare in Assisted Living
WHAT THIS MEANS FOR YOU: This editorial discussed the difficulty providing mental and behavioral healthcare in assisted living. Increasing numbers of residents experience high rates of behavioral health issues, but only 40% of communities offer treatment for these issues, despite the fact that lack of treatment is associated with negative outcomes such as severe depression and suicidal ideation. To improve behavioral healthcare in assisted living, adequate staffing and staff education is required, as well as insurance reimbursements for mental health services at similar levels to those for medical care.
The Complexity of Providing Behavioral Healthcare in Assisted Living
WHAT THIS MEANS FOR YOU: This editorial discussed the difficulty providing mental and behavioral healthcare in assisted living. Increasing numbers of residents experience high rates of behavioral health issues, but only 40% of communities offer treatment for these issues, despite the fact that lack of treatment is associated with negative outcomes such as severe depression and suicidal ideation. To improve behavioral healthcare in assisted living, adequate staffing and staff education is required, as well as insurance reimbursements for mental health services at similar levels to those for medical care.
Exploring Constraints to Well-Being for Older Adults in Transition Into an Assisted Living Home: A Qualitative Study
WHAT THIS MEANS FOR YOU: A theory-based thematic analysis was conducted on 14 interviews with assisted living residents from one community in the rural southeastern US. When asked to report experiences when transitioning to the community, residents felt a loss of independence, space, and belongings due to necessary downsizing. Results support the Modified Constraints to Wellbeing model, which theorizes that structural and intrapersonal constraints (e.g., loss of independence) lead to changes in social leisure pursuits after transitioning into assisted living, which negatively affects wellbeing. However, more research is needed.
Exploring Constraints to Well-Being for Older Adults in Transition Into an Assisted Living Home: A Qualitative Study
WHAT THIS MEANS FOR YOU: A theory-based thematic analysis was conducted on 14 interviews with assisted living residents from one community in the rural southeastern US. When asked to report experiences when transitioning to the community, residents felt a loss of independence, space, and belongings due to necessary downsizing. Results support the Modified Constraints to Wellbeing model, which theorizes that structural and intrapersonal constraints (e.g., loss of independence) lead to changes in social leisure pursuits after transitioning into assisted living, which negatively affects wellbeing. However, more research is needed.
Attachment Behaviours in Adults with Intellectual Disabilities in Assisted Living Facilities: Representations from Direct-Care Staff
WHAT THIS MEANS FOR YOU: In this study, 19 support staff from 7 assisted living communities in Belgium were interviewed to understand about how adults with intellectual disabilities related to these staff. Themes revealed that staff often struggled finding a balance between supporting select attachment behaviors and maintaining a professional distance from residents to prevent negative impact on their work.
Attachment Behaviours in Adults with Intellectual Disabilities in Assisted Living Facilities: Representations from Direct-Care Staff
WHAT THIS MEANS FOR YOU: In this study, 19 support staff from 7 assisted living communities in Belgium were interviewed to understand about how adults with intellectual disabilities related to these staff. Themes revealed that staff often struggled finding a balance between supporting select attachment behaviors and maintaining a professional distance from residents to prevent negative impact on their work.
