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.

Social

Facility-Level Variation of Resident Loneliness in Assisted Living and Associated Organizational Context Factors: A Repeated Cross-Sectional Study

May 1, 2025
WHAT THIS MEANS FOR YOU: This Canadian cross-sectional study used quarterly data (2017-2021) from the Resident Assessment Instrument - Home Care to assess AL resident loneliness and factors associated with loneliness. At the systems level, loneliness did not change during the course of pandemic, but levels did vary between communities. Factors associated with reducing loneliness at the community level include caregiver involvement, essential visitor policies, and video calls with volunteers/spiritual leaders.

Facility-Level Variation of Resident Loneliness in Assisted Living and Associated Organizational Context Factors: A Repeated Cross-Sectional Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This Canadian cross-sectional study used quarterly data (2017-2021) from the Resident Assessment Instrument – Home Care to assess AL resident loneliness and factors associated with loneliness. At the systems level, loneliness did not change during the course of pandemic, but levels did vary between communities. Factors associated with reducing loneliness at the community level include caregiver involvement, essential visitor policies, and video calls with volunteers/spiritual leaders.

Inactivity Is Isolation: Insights from a Sedentary Time Intervention in Assisted Living

Apr 1, 2025
WHAT THIS MEANS FOR YOU: This exploratory study included 18 residents across three Canadian assisted living facilities who participated in a 12-week intervention to promote active aging. In post-intervention focus groups, 5 themes emerged: intervention effectiveness, physical and social engagement work together, influence of congregate living environment, environment supporting relationships, and personal preferences. The intervention was considered feasible and acceptable by participants, and could merit further testing.

Inactivity Is Isolation: Insights from a Sedentary Time Intervention in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This exploratory study included 18 residents across three Canadian assisted living facilities who participated in a 12-week intervention to promote active aging. In post-intervention focus groups, 5 themes emerged: intervention effectiveness, physical and social engagement work together, influence of congregate living environment, environment supporting relationships, and personal preferences. The intervention was considered feasible and acceptable by participants, and could merit further testing.

The Impact of Enhanced Group Activity Kits (EGAKs) on Well-being of Persons with Dementia

Jan 1, 2025
WHAT THIS MEANS FOR YOU: This study examined 123 people living with dementia (PLwD) from 6 nursing centers and 4 adult day units in Israel to investigate the impact of group activities and whether group activity kits (EGAKs) enhanced activity quality. Use of EGAKs significantly improved resident well-being compared to activities without EGAKs, and participating in no activities at all significantly lowered well-being, supporting possible implementation of EGAKs to improve group activities for residents.

The Impact of Enhanced Group Activity Kits (EGAKs) on Well-being of Persons with Dementia

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined 123 people living with dementia (PLwD) from 6 nursing centers and 4 adult day units in Israel to investigate the impact of group activities and whether group activity kits (EGAKs) enhanced activity quality. Use of EGAKs significantly improved resident well-being compared to activities without EGAKs, and participating in no activities at all significantly lowered well-being, supporting possible implementation of EGAKs to improve group activities for residents.

The Meaningful Engagement Assessment for Residents with Dementia in Assisted Living Settings

Jan 1, 2025
WHAT THIS MEANS FOR YOU: This study tested the Meaningful Engagement Assessment (MEA) tool with 31 residents with mild to severe dementia in two assisted living communities. The MEA is designed to create individualized care plannning for residents. With brief training, this pilot study revealed that the tool can feasibly be used by staff to promote meaningful activity for AL residents.

The Meaningful Engagement Assessment for Residents with Dementia in Assisted Living Settings

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study tested the Meaningful Engagement Assessment (MEA) tool with 31 residents with mild to severe dementia in two assisted living communities. The MEA is designed to create individualized care plannning for residents. With brief training, this pilot study revealed that the tool can feasibly be used by staff to promote meaningful activity for AL residents.

Measurement of Quality in Assisted Living in the United States of America: A Scoping Review

Jan 1, 2025
WHAT THIS MEANS FOR YOU: This scoping review examined 49 peer-reviewed and 45 gray literature articles from 2009-2019 to assess approaches to, and indicators of, quality in assisted living. After thematic analysis, nine domains emerged, with resident qualiy of life and satisfaction being the most prioritized. These nine domains may help inform future standardized quality measurement for AL settings.

Measurement of Quality in Assisted Living in the United States of America: A Scoping Review

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This scoping review examined 49 peer-reviewed and 45 gray literature articles from 2009-2019 to assess approaches to, and indicators of, quality in assisted living. After thematic analysis, nine domains emerged, with resident qualiy of life and satisfaction being the most prioritized. These nine domains may help inform future standardized quality measurement for AL settings.

“What Does ‘Age-Friendly’ Mean to You?”: The Role of Microaggressions in a Retirement and Assisted Living Community

Dec 1, 2024
WHAT THIS MEANS FOR YOU: This case study compared four residents' perspectives on the age-friendliness of an AL in the Midwest using semi-structured interviews and observational data. Themes of built design vs. identity of age-friendliness, resident-resident microaggressions, and desired experiences of age-friendliness emerged. Visible diversity created experiences of ableism and racism, whereas invisible diversity did not have the same negative effects. Resident-resident microaggressions undermined the age-friendliness of the facility.

“What Does ‘Age-Friendly’ Mean to You?”: The Role of Microaggressions in a Retirement and Assisted Living Community

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This case study compared four residents’ perspectives on the age-friendliness of an AL in the Midwest using semi-structured interviews and observational data. Themes of built design vs. identity of age-friendliness, resident-resident microaggressions, and desired experiences of age-friendliness emerged. Visible diversity created experiences of ableism and racism, whereas invisible diversity did not have the same negative effects. Resident-resident microaggressions undermined the age-friendliness of the facility.

Examining Engagement Calendar Deviations in Assisted Living: A Focus on Residents With Dementia

Dec 1, 2024
WHAT THIS MEANS FOR YOU: This study used data from 3 AL communities over one year to examine deviations from scheduled activity programming, identify influential factors, and understand the outcomes on residents. The analysis showed general adherence to calendars, but deviations did occur. Staffing, capacity, programming guidance and support, staff attitudes, and unforeseen circumstances all influenced these deviations. Cancellations of programming were more detrimental to resident well-being than substitutions.

Examining Engagement Calendar Deviations in Assisted Living: A Focus on Residents With Dementia

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study used data from 3 AL communities over one year to examine deviations from scheduled activity programming, identify influential factors, and understand the outcomes on residents. The analysis showed general adherence to calendars, but deviations did occur. Staffing, capacity, programming guidance and support, staff attitudes, and unforeseen circumstances all influenced these deviations. Cancellations of programming were more detrimental to resident well-being than substitutions.

The Relationship between Perceived Engagement in Meaningful Activity and Behavioral and Psychological Symptoms of Dementia among Assisted Living Residents

Nov 1, 2024
WHAT THIS MEANS FOR YOU: This study of 71 residents with dementia in 5 AL communities assessed the relationship between engagement in meaningful activities and symptoms of dementia. Perceived engagement in meaningful activities was significantly associated with decreased agitation, but not apathy, depression, or irritability.

The Relationship between Perceived Engagement in Meaningful Activity and Behavioral and Psychological Symptoms of Dementia among Assisted Living Residents

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study of 71 residents with dementia in 5 AL communities assessed the relationship between engagement in meaningful activities and symptoms of dementia. Perceived engagement in meaningful activities was significantly associated with decreased agitation, but not apathy, depression, or irritability.

Participants’ Baseline Characteristics and Feedback of the Nature-Based Social Intervention “Friends in Nature” among Lonely Older Adults in Assisted Living Facilities in Finland: A Randomised Controlled Trial of the RECETAS EU-Project

Oct 1, 2024
WHAT THIS MEANS FOR YOU: This Finnish study conducted a randomized controlled trial of a "friends in nature" intervention for 319 lonely older adult participants from 22 AL communities. General alleviation of loneliness was seen in 57% of residents who received the friends in nature intervention. When asked for their feedback, participants appreciated the experience and 96% would recommend the intervention to other older adults.

Participants’ Baseline Characteristics and Feedback of the Nature-Based Social Intervention “Friends in Nature” among Lonely Older Adults in Assisted Living Facilities in Finland: A Randomised Controlled Trial of the RECETAS EU-Project

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This Finnish study conducted a randomized controlled trial of a “friends in nature” intervention for 319 lonely older adult participants from 22 AL communities. General alleviation of loneliness was seen in 57% of residents who received the friends in nature intervention. When asked for their feedback, participants appreciated the experience and 96% would recommend the intervention to other older adults.

Aging in Isolation: Sexual Orientation Differences in Navigating Cognitive Decline

Sep 1, 2024
WHAT THIS MEANS FOR YOU: This cross-sectional study examined data from 2015-19 to investigate subjective cognitive decline differences among individuals with different sexual orientations. Sexual minorities (e.g., lesbian, gay, bisexual, and queer individuals) were more likely to experience cognitive decline, and sexual minority women were less likely to receive social support than non-sexual minority individuals. Therefore, specific strategies to increase support and services to prevent cognitive decline in sexual minority populations are recommended.

Aging in Isolation: Sexual Orientation Differences in Navigating Cognitive Decline

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This cross-sectional study examined data from 2015-19 to investigate subjective cognitive decline differences among individuals with different sexual orientations. Sexual minorities (e.g., lesbian, gay, bisexual, and queer individuals) were more likely to experience cognitive decline, and sexual minority women were less likely to receive social support than non-sexual minority individuals. Therefore, specific strategies to increase support and services to prevent cognitive decline in sexual minority populations are recommended.

Well-Being Outcomes from the Delivery of RASCALs, a Group Activity Intervention Using Nature-Focused Livestream Broadcasts

Aug 1, 2024
WHAT THIS MEANS FOR YOU: This study pilot tested the effectiveness of RASCALs, a nature-based group activity program, to improve resident well-being in an AL community in Texas. The test group of 16 residents that lived in buildings that received RASCALs programming showed increased positive relations with others as measured by a wellbeing scale as compared to the 17 residents who did not receive programming.

Well-Being Outcomes from the Delivery of RASCALs, a Group Activity Intervention Using Nature-Focused Livestream Broadcasts

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study pilot tested the effectiveness of RASCALs, a nature-based group activity program, to improve resident well-being in an AL community in Texas. The test group of 16 residents that lived in buildings that received RASCALs programming showed increased positive relations with others as measured by a wellbeing scale as compared to the 17 residents who did not receive programming.

Family Involvement among Oregon Adult Foster Home Residents, 2018-2023

Aug 1, 2024
WHAT THIS MEANS FOR YOU: This study used cross-sectional data from 2017-2022 from Adult Foster Homes (AFHs) in Oregon to examine trends in family involvement and home and resident characteristics. Data showed declines in familial social visits and help with appointments in 2021/22 following COVID-19, but by 2023 social visits were back to pre-pandemic levels. However, there was less familial support in going on outings and getting to medical appointments, and there were disparities in that rural and Medicaid AFHs had less family support for residents in all areas. The continued decline in medical appointment and outings support presents concerns for resident socio-emotional well-being.

Family Involvement among Oregon Adult Foster Home Residents, 2018-2023

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study used cross-sectional data from 2017-2022 from Adult Foster Homes (AFHs) in Oregon to examine trends in family involvement and home and resident characteristics. Data showed declines in familial social visits and help with appointments in 2021/22 following COVID-19, but by 2023 social visits were back to pre-pandemic levels. However, there was less familial support in going on outings and getting to medical appointments, and there were disparities in that rural and Medicaid AFHs had less family support for residents in all areas. The continued decline in medical appointment and outings support presents concerns for resident socio-emotional well-being.

A Qualitative Study of a Sporting Memories Program in South Australia: Belonging, Participation, and Social Connection

Jul 1, 2024
WHAT THIS MEANS FOR YOU: This study examined 16 participants' opinions on the Sporting Memories program in South Australia using focus groups. The Sporting Memory program utilizes reminiscing about sports to achieve social benefits. Themes of feeling free to talk, not feeling left out, and a chance to share and learn emerged, and participants did indeed feel that they built social connections.

A Qualitative Study of a Sporting Memories Program in South Australia: Belonging, Participation, and Social Connection

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined 16 participants’ opinions on the Sporting Memories program in South Australia using focus groups. The Sporting Memory program utilizes reminiscing about sports to achieve social benefits. Themes of feeling free to talk, not feeling left out, and a chance to share and learn emerged, and participants did indeed feel that they built social connections.

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.

Social Support, Social Participation, and Life Accomplishment of Older Adult Residents of Assisted Living Facilities and Their Adjoining Communities

Dec 1, 2023
WHAT THIS MEANS FOR YOU: A study of 54 assisted living residents and 66 community-dwelling older adults in Nigeria found assisted living residents had more limited social participation compared to those in the community; however, both groups perceived a similar amount of social support. Assisted living residents also felt that they had lower life accomplishment than community-dwelling participants. Promoting social participation, especially in assisted living, might improve both social wellbeing and self-perception.

Social Support, Social Participation, and Life Accomplishment of Older Adult Residents of Assisted Living Facilities and Their Adjoining Communities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A study of 54 assisted living residents and 66 community-dwelling older adults in Nigeria found assisted living residents had more limited social participation compared to those in the community; however, both groups perceived a similar amount of social support. Assisted living residents also felt that they had lower life accomplishment than community-dwelling participants. Promoting social participation, especially in assisted living, might improve both social wellbeing and self-perception.

From 65 to 103, Older Adults Experience Virtual Reality Differently Depending on Their Age: Evidence from a Large-Scale Field Study in Nursing Homes and Assisted Living Facilities

Dec 1, 2023
WHAT THIS MEANS FOR YOU: Two related studies examined the experiences of 245 assisted living and nursing homes residents across 10 US states who used virtual reality (VR), as well as 39 caregiving staff who facilitated the VR experiences. Older residents enjoyed VR less, a result that was less strong when asked about other technologies such as phones and voice assistants. Staff who facilitated the experiences saw VR as generally enjoyable compared to other work activities and felt it improved their relationships with residents.

From 65 to 103, Older Adults Experience Virtual Reality Differently Depending on Their Age: Evidence from a Large-Scale Field Study in Nursing Homes and Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Two related studies examined the experiences of 245 assisted living and nursing homes residents across 10 US states who used virtual reality (VR), as well as 39 caregiving staff who facilitated the VR experiences. Older residents enjoyed VR less, a result that was less strong when asked about other technologies such as phones and voice assistants. Staff who facilitated the experiences saw VR as generally enjoyable compared to other work activities and felt it improved their relationships with residents.

Social Connectedness Resource Preferences of Older Adults in Assisted Living: A Scoping Review Based on the WHO-ICF Framework

Sep 1, 2023
WHAT THIS MEANS FOR YOU: A literature review examined the social activities preferred by assisted living residents, finding that residents preferred social activities organized by the community, such as games and outings. They also preferred civic life activities (e.g., volunteering) to connect with the broader community. Older residents and those living in larger communities tended to prefer activities provided by the community, while younger residents preferred more demanding physical activities.

Social Connectedness Resource Preferences of Older Adults in Assisted Living: A Scoping Review Based on the WHO-ICF Framework

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A literature review examined the social activities preferred by assisted living residents, finding that residents preferred social activities organized by the community, such as games and outings. They also preferred civic life activities (e.g., volunteering) to connect with the broader community. Older residents and those living in larger communities tended to prefer activities provided by the community, while younger residents preferred more demanding physical activities.

Experiences of Social Frailty Among Rural Community-Dwelling and Assisted-Living Older Adults: A Qualitative Study

Apr 1, 2023
WHAT THIS MEANS FOR YOU: Interviews were conducted with 38 older adults in rural villages and AL communities in the Netherlands to compare the effect of social frailty, measured by access to social resources and activities that fulfill social needs. Social frailty is the actual or potential loss of social resources and activities over time, leading to loneliness and isolation. Older adults who live independently in their own communities experienced self-reported loneliness, while those living in AL communities reported higher participation in social activities. Therefore, for some older adults, a residential setting may be preferable to aging in place to address loneliness and social frailty.

Experiences of Social Frailty Among Rural Community-Dwelling and Assisted-Living Older Adults: A Qualitative Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Interviews were conducted with 38 older adults in rural villages and AL communities in the Netherlands to compare the effect of social frailty, measured by access to social resources and activities that fulfill social needs. Social frailty is the actual or potential loss of social resources and activities over time, leading to loneliness and isolation. Older adults who live independently in their own communities experienced self-reported loneliness, while those living in AL communities reported higher participation in social activities. Therefore, for some older adults, a residential setting may be preferable to aging in place to address loneliness and social frailty.

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.

Interactions, Relationships and Belonging: Comparing Social Connectedness and Perceived Isolation among Older Women Living Alone in Private Homes and in Assisted Living

Jul 1, 2022
WHAT THIS MEANS FOR YOU: This qualitative study of social connections among 16 women aged 75 and older found that those living in the community focus on feeling connected to the world at large, while those in assisted living have more casual interactions and feel like they are a part of the community. Most women in both groups did not experience perceived isolation; they had adjusted their expectations about socializing to fit their living situation.

Interactions, Relationships and Belonging: Comparing Social Connectedness and Perceived Isolation among Older Women Living Alone in Private Homes and in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This qualitative study of social connections among 16 women aged 75 and older found that those living in the community focus on feeling connected to the world at large, while those in assisted living have more casual interactions and feel like they are a part of the community. Most women in both groups did not experience perceived isolation; they had adjusted their expectations about socializing to fit their living situation.

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.

Assisted Living Residents With Dementia: Being Out in the World and Negotiating Connections

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This year-long study observed 33 individuals and their caregivers in 4 assisted living communities, focusing on the significance of outdoor and offsite activities for persons living with dementia. Data included 1,560 observation hours, 114 interviews with residents, staff, family, and visitors, and resident record reviews. Qualitative findings suggested that engaging with others and with nature is important for better quality of life. Most residents were able to at least occasionally go out, and those who went outdoors generally had positive experiences, but not all experiences were positive.

Assisted Living Residents With Dementia: Being Out in the World and Negotiating Connections

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This year-long study observed 33 individuals and their caregivers in 4 assisted living communities, focusing on the significance of outdoor and offsite activities for persons living with dementia. Data included 1,560 observation hours, 114 interviews with residents, staff, family, and visitors, and resident record reviews. Qualitative findings suggested that engaging with others and with nature is important for better quality of life. Most residents were able to at least occasionally go out, and those who went outdoors generally had positive experiences, but not all experiences were positive.

“You Lose Some Good Friends”: Death and Grief in Assisted Living

Mar 1, 2022
WHAT THIS MEANS FOR YOU: In a qualitative study including interviews with 18 residents in 21 assisted living communities, as well as reviews of community documents and observational field notes, residents reported that staff communication and community-level memorials following residents’ death were not consistent with a “family-like” atmosphere, and residents’ grief took many forms.

“You Lose Some Good Friends”: Death and Grief in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: In a qualitative study including interviews with 18 residents in 21 assisted living communities, as well as reviews of community documents and observational field notes, residents reported that staff communication and community-level memorials following residents’ death were not consistent with a “family-like” atmosphere, and residents’ grief took many forms.

Exploring the Effectiveness of Virtual Compassionate Presence Sessions in Reducing Loneliness and Isolation among Assisted-Living Older Adults: A Pilot Study

Mar 1, 2022
WHAT THIS MEANS FOR YOU: A pilot study investigated the effectiveness of virtual compassionate presence (CP) sessions in reducing loneliness and isolation among older adults in AL when facilitated by college students trained in CP. CP involves deep, attentive, and nonjudgmental listening while being fully present. Eighteen older adults participated in CP sessions over 10 weeks and were interviewed 2 months after the last session. Semi-structured interview results revealed a self-reported decrease in participants’ feelings of isolation and loneliness and an increase in overall mood.

Exploring the Effectiveness of Virtual Compassionate Presence Sessions in Reducing Loneliness and Isolation among Assisted-Living Older Adults: A Pilot Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A pilot study investigated the effectiveness of virtual compassionate presence (CP) sessions in reducing loneliness and isolation among older adults in AL when facilitated by college students trained in CP. CP involves deep, attentive, and nonjudgmental listening while being fully present. Eighteen older adults participated in CP sessions over 10 weeks and were interviewed 2 months after the last session. Semi-structured interview results revealed a self-reported decrease in participants’ feelings of isolation and loneliness and an increase in overall mood.