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.

Mental Health

Two New Positive Psychosocial Measures for Persons Living with Dementia

Feb 1, 2025
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

by Lea Efird-Green

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

Feb 1, 2025
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

by Lea Efird-Green

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

Dec 1, 2024
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

by Lea Efird-Green

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.

A New Measure of Professional Caregiver Coping in Long-Term Care: The LTC COPE

Dec 1, 2024
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

by Lea Efird-Green

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.

The Role of Workday Characteristics on Perceived Stress and Time Pressure among Nurses in Finnish Long-Term Care – A Cross-Sectional Study

Dec 1, 2024
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

by Lea Efird-Green

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.

Progress of Rehabilitation in Assisted Living for Mentally Ill According to STAX-SA Taxonomy

Nov 1, 2024
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

by Lea Efird-Green

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

Nov 1, 2024
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

by Lea Efird-Green

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

Aug 1, 2024
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

by Lea Efird-Green

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

Jun 10, 2024
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

by Lea Efird-Green

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 […]

Serious Mental Illness in Assisted Living Communities: Association with Nursing Home Placement

May 1, 2024
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

by Lea Efird-Green

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.

Estimated Prevalence of Resident-to-Resident Aggression in Assisted Living

May 1, 2024
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

by Lea Efird-Green

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.

Examining Pain, Function, Behavioral Symptoms and Associations with Engagement in Meaningful Activity for Residents with Dementia in Assisted Living

Apr 1, 2024
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

by Lea Efird-Green

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.

Assisted Living Residents with Dementia: Disparities in Mental Health Services Pre and During COVID-19

Apr 1, 2024
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

by Lea Efird-Green

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.

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

Nov 1, 2023
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

by Lea Efird-Green

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

Oct 1, 2023
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

by Lea Efird-Green

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

Jul 1, 2023
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

by Lea Efird-Green

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

Jun 1, 2023
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

by Lea Efird-Green

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.

“I Have a Lotta Sad Feelin'” – Unaddressed Mental Health Needs and Self-Support Strategies in Medicaid-Funded Assisted Living

Jun 1, 2023
WHAT THIS MEANS FOR YOU: This study investigated mental health needs and barriers among residents at Medicaid-funded AL communities. At one AL community in the Bronx, 13 residents completed questionnaires and interviews; analysis revealed patterns of mental health needs, feelings of losing control, mistrust of organizational staff, and lack of resources and support.

“I Have a Lotta Sad Feelin'” – Unaddressed Mental Health Needs and Self-Support Strategies in Medicaid-Funded Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study investigated mental health needs and barriers among residents at Medicaid-funded AL communities. At one AL community in the Bronx, 13 residents completed questionnaires and interviews; analysis revealed patterns of mental health needs, feelings of losing control, mistrust of organizational staff, and lack of resources and support.

Well-being of professional older adults’ caregivers in Alberta’s assisted living and long-term care facilities: a cross-sectional study

Feb 1, 2023
WHAT THIS MEANS FOR YOU: A study in AL and other long-term care communities in Alberta assessed nurses’ and professional care aides’ physical, mental, and emotional health, behavior, stress, quality of life, turnover, and absenteeism. Mental and emotional health, quality of life, and stress related to turnover and absenteeism. Although 68% of caregivers reported being satisfied with their general health, they experienced heavy workloads and high stress. These issues may result in decreased job satisfaction, absenteeism, and higher turnover.

Well-being of professional older adults’ caregivers in Alberta’s assisted living and long-term care facilities: a cross-sectional study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A study in AL and other long-term care communities in Alberta assessed nurses’ and professional care aides’ physical, mental, and emotional health, behavior, stress, quality of life, turnover, and absenteeism. Mental and emotional health, quality of life, and stress related to turnover and absenteeism. Although 68% of caregivers reported being satisfied with their general health, they experienced heavy workloads and high stress. These issues may result in decreased job satisfaction, absenteeism, and higher turnover.

Coping Behaviors and Health Status during the COVID-19 Pandemic among Caregivers of Assisted Living Residents in Western Canada

Dec 1, 2022
WHAT THIS MEANS FOR YOU: Surveys from 673 assisted living direct caregivers revealed that coping behaviors such as alcohol and smoking/cannabis use, and psychotropic drug use increased during the first two waves of the COVID-19 pandemic and were more common among caregivers who had anxiety or depression symptoms before the pandemic. These caregivers are thus particularly vulnerable to negative coping behaviors during stressful events and may require additional support.

Coping Behaviors and Health Status during the COVID-19 Pandemic among Caregivers of Assisted Living Residents in Western Canada

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Surveys from 673 assisted living direct caregivers revealed that coping behaviors such as alcohol and smoking/cannabis use, and psychotropic drug use increased during the first two waves of the COVID-19 pandemic and were more common among caregivers who had anxiety or depression symptoms before the pandemic. These caregivers are thus particularly vulnerable to negative coping behaviors during stressful events and may require additional support.

Caregivers’ Concerns about Assisted Living Residents’ Mental Health during the COVID-19 Pandemic: A Cross-Sectional Survey Study

Sep 1, 2022
WHAT THIS MEANS FOR YOU: Surveys with 673 caregivers from Western Canada found that concerns about residents' depressed mood, loneliness, and anxiety doubled three months after the COVID-19 pandemic started, compared with three months before the pandemic. Factors that may alleviate concerns in the future include improving residents' access to counseling services and better informing caregivers about resident care.

Caregivers’ Concerns about Assisted Living Residents’ Mental Health during the COVID-19 Pandemic: A Cross-Sectional Survey Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Surveys with 673 caregivers from Western Canada found that concerns about residents’ depressed mood, loneliness, and anxiety doubled three months after the COVID-19 pandemic started, compared with three months before the pandemic. Factors that may alleviate concerns in the future include improving residents’ access to counseling services and better informing caregivers about resident care.

Recommendations for Medical and Mental Health Care in Assisted Living Based on an Expert Delphi Consensus Panel

Sep 1, 2022
Importance: Assisted living (AL) is the largest provider of residential long-term care in the US, and the morbidity of AL residents has been rising. However, AL is not a health care setting, and concern has been growing about residents’ medical and mental health needs. No guidance exists to inform this care. Objective: To identify consensus […]

Recommendations for Medical and Mental Health Care in Assisted Living Based on an Expert Delphi Consensus Panel

by Lea Efird-Green

Importance: Assisted living (AL) is the largest provider of residential long-term care in the US, and the morbidity of AL residents has been rising. However, AL is not a health care setting, and concern has been growing about residents’ medical and mental health needs. No guidance exists to inform this care. Objective: To identify consensus […]

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.

A Home, an Institution and a Community – Frames of Social Relationships and Interaction in Assisted Living

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Through qualitative observations of an AL community and interviews with ten residents, those who perceived the assisted living community as a home reported more meaningful, informal relationships. When the community was perceived as an institution, residents reported impersonal, formal interactions.

A Home, an Institution and a Community – Frames of Social Relationships and Interaction in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Through qualitative observations of an AL community and interviews with ten residents, those who perceived the assisted living community as a home reported more meaningful, informal relationships. When the community was perceived as an institution, residents reported impersonal, formal interactions.