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.

Academic Publication

As-Needed Prescribing and Administration of Psychotropic Medications in Assisted Living: A 7-State Study

Jun 1, 2022
WHAT THIS MEANS FOR YOU: In 250 assisted living communities in 7 states, 10% of residents were prescribed psychotropic medications; less than 3% were administered a psychotropic medication in the previous week. Most (70%) prescriptions had a written reason for administration. Residents with both dementia and a psychiatric diagnosis were more likely to have a prescription, and communities that were larger or had a higher proportion of dementia care beds had a higher prescription rate.

As-Needed Prescribing and Administration of Psychotropic Medications in Assisted Living: A 7-State Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: In 250 assisted living communities in 7 states, 10% of residents were prescribed psychotropic medications; less than 3% were administered a psychotropic medication in the previous week. Most (70%) prescriptions had a written reason for administration. Residents with both dementia and a psychiatric diagnosis were more likely to have a prescription, and communities that were larger or had a higher proportion of dementia care beds had a higher prescription rate.

Antibiotic Deescalation Opportunities for Residents in Assisted Living Facilities

Jun 1, 2022
WHAT THIS MEANS FOR YOU: During one-year in three assisted living communities, over 52% of the 106 residents were prescribed an antibiotic medication, similar to the rate of prescribing in nursing homes. Different from nursing homes, assisted living prescribers appeared less likely to reduce antibiotic use, and more likely to switch from narrow- to broad-spectrum antibiotics. Differences may be due to less frequent on-site visits of prescribing physicians in assisted living, which could lead to less familiarity with residents.

Antibiotic Deescalation Opportunities for Residents in Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: During one-year in three assisted living communities, over 52% of the 106 residents were prescribed an antibiotic medication, similar to the rate of prescribing in nursing homes. Different from nursing homes, assisted living prescribers appeared less likely to reduce antibiotic use, and more likely to switch from narrow- to broad-spectrum antibiotics. Differences may be due to less frequent on-site visits of prescribing physicians in assisted living, which could lead to less familiarity with residents.

Engagement with life among the oldest-old in assisted living facilities: enriching activities and developmental adaptation to physical loss

May 1, 2022
WHAT THIS MEANS FOR YOU: This study examined the activities, motivations, and barriers to activity engagement of 20 residents ages 80-94 residing in two AL communities. Resulting themes included a common longing for enriching activities among all residents; those with functional limitations found it harder to engage in such activities; and participants perceived the activities provided in their communities as being geared toward those with cognitive impairment. Thus, participants who were cognitively fit but had significant mobility impairments were in most need of engaging community activities.

Engagement with life among the oldest-old in assisted living facilities: enriching activities and developmental adaptation to physical loss

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined the activities, motivations, and barriers to activity engagement of 20 residents ages 80-94 residing in two AL communities. Resulting themes included a common longing for enriching activities among all residents; those with functional limitations found it harder to engage in such activities; and participants perceived the activities provided in their communities as being geared toward those with cognitive impairment. Thus, participants who were cognitively fit but had significant mobility impairments were in most need of engaging community activities.

End-Of-Life Care In Assisted Living Communities: Race And Ethnicity, Dual Enrollment Status, And State Regulations

May 1, 2022
WHAT THIS MEANS FOR YOU: This study examined end-of-life care in assisted living – specifically whether residents died in the community or elsewhere and received hospice care -- and whether these were associated with select factors. Among 100,783 Medicare beneficiaries who died in 16,560 communities during 2018–2019, nearly 60% died in their community, with 84% receiving hospice care. Communities with more Medicare-Medicaid enrollment had more residents dying in the community, and white residents were more likely than Black ones to use hospice care. In states with less strict assisted living regulations (e.g., for dementia care, admission/retention, and staffing/training), residents were more likely to die outside of the community (e.g., in a hospital or nursing home).

End-Of-Life Care In Assisted Living Communities: Race And Ethnicity, Dual Enrollment Status, And State Regulations

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined end-of-life care in assisted living – specifically whether residents died in the community or elsewhere and received hospice care — and whether these were associated with select factors. Among 100,783 Medicare beneficiaries who died in 16,560 communities during 2018–2019, nearly 60% died in their community, with 84% receiving hospice care. Communities with more Medicare-Medicaid enrollment had more residents dying in the community, and white residents were more likely than Black ones to use hospice care. In states with less strict assisted living regulations (e.g., for dementia care, admission/retention, and staffing/training), residents were more likely to die outside of the community (e.g., in a hospital or nursing home).

“We Weathered the Storm”: A Qualitative Phenomenological Study of the Lived Experience of Assisted Living Administrators during the COVID-19 Pandemic

May 1, 2022
WHAT THIS MEANS FOR YOU: A qualitative study interviewing five assisted living administrators about their experiences during the COVID-19 pandemic found frequent changes in the administrators' experiences during the pandemic, including having limited resources and responding to rapid policy shifts.

“We Weathered the Storm”: A Qualitative Phenomenological Study of the Lived Experience of Assisted Living Administrators during the COVID-19 Pandemic

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A qualitative study interviewing five assisted living administrators about their experiences during the COVID-19 pandemic found frequent changes in the administrators’ experiences during the pandemic, including having limited resources and responding to rapid policy shifts.

Developing a Toolkit to Improve Resident and Family Engagement in the Safety of Assisted Living: Engage – A Stakeholder-Engaged Research Protocol

May 1, 2022
WHAT THIS MEANS FOR YOU: This study protocol describes the methods to be used in developing a toolkit for increased resident and family engagement in assisted living community safety planning; it includes a scoping review, qualitative interviews, and stakeholder meetings. The study’s goals include identifying, prioritizing, and evaluating existing engagement methods around safety concerns in assisted living and developing a toolkit that helps residents and families engage more frequently.

Developing a Toolkit to Improve Resident and Family Engagement in the Safety of Assisted Living: Engage – A Stakeholder-Engaged Research Protocol

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study protocol describes the methods to be used in developing a toolkit for increased resident and family engagement in assisted living community safety planning; it includes a scoping review, qualitative interviews, and stakeholder meetings. The study’s goals include identifying, prioritizing, and evaluating existing engagement methods around safety concerns in assisted living and developing a toolkit that helps residents and families engage more frequently.

Effects of the Mobility-Fit Physical Activity Program on Strength and Mobility in Older Adults in Assisted Living: A Feasibility Study

Apr 1, 2022
WHAT THIS MEANS FOR YOU: In a 12-week study of 30 assisted living residents, the Mobility-Fit program - which focuses on upper-limb strength to help prevent falls and includes exercises targeting strength, agility, coordination, and balance - participants experienced improvements in knee extension strength, reaction time, and time to stand from a sitting position.

Effects of the Mobility-Fit Physical Activity Program on Strength and Mobility in Older Adults in Assisted Living: A Feasibility Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: In a 12-week study of 30 assisted living residents, the Mobility-Fit program – which focuses on upper-limb strength to help prevent falls and includes exercises targeting strength, agility, coordination, and balance – participants experienced improvements in knee extension strength, reaction time, and time to stand from a sitting position.

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.

Bridging the Transition to Assisted Living: A Framework for Faith Community Nursing

Apr 1, 2022
WHAT THIS MEANS FOR YOU: Using an example of an 85-year-old resident, the article proposes a framework for faith community nursing, emphasizing observation, meaningful conversations, advocacy, and assertive communication to ease the move from independent to assisted living.

Bridging the Transition to Assisted Living: A Framework for Faith Community Nursing

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Using an example of an 85-year-old resident, the article proposes a framework for faith community nursing, emphasizing observation, meaningful conversations, advocacy, and assertive communication to ease the move from independent to assisted living.

Does Service Provider Matter during a Pandemic? COVID-19 Cases and Deaths among Nonprofit vs. For-Profit Assisted Living Facilities in Florida

Apr 1, 2022
WHAT THIS MEANS FOR YOU: This study investigated the relationship of ownership (nonprofit vs. for-profit) to Florida assisted living communities’ responses to COVID-19. In total, 672 of 3,019 communities reported at least one positive case by June 2020. Nonprofit communities had fewer cases, although there was no significant difference in resident deaths. Additionally, whether nursing services were provided in the community mattered in protecting residents from COVID-19 infections (i.e., not providing any nursing services was associated with more infections).

Does Service Provider Matter during a Pandemic? COVID-19 Cases and Deaths among Nonprofit vs. For-Profit Assisted Living Facilities in Florida

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study investigated the relationship of ownership (nonprofit vs. for-profit) to Florida assisted living communities’ responses to COVID-19. In total, 672 of 3,019 communities reported at least one positive case by June 2020. Nonprofit communities had fewer cases, although there was no significant difference in resident deaths. Additionally, whether nursing services were provided in the community mattered in protecting residents from COVID-19 infections (i.e., not providing any nursing services was associated with more infections).

SARS-CoV-2 in Assisted Living: Mortality and Asymptomatic Infection

Apr 1, 2022
WHAT THIS MEANS FOR YOU: Two assisted living communities in New York had 42% of residents test positive for COVID-19 in April 2020; 68% of infected residents were asymptomatic. The frequency of asymptomatic cases may have contributed to a more widespread infection and mortality; 25% of resident deaths in these communities in April 2020 were due to COVID-19.

SARS-CoV-2 in Assisted Living: Mortality and Asymptomatic Infection

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Two assisted living communities in New York had 42% of residents test positive for COVID-19 in April 2020; 68% of infected residents were asymptomatic. The frequency of asymptomatic cases may have contributed to a more widespread infection and mortality; 25% of resident deaths in these communities in April 2020 were due to COVID-19.

Physical Activity and Sedentary Behavior of Residents in Assisted Living: A Preliminary Study

Apr 1, 2022
WHAT THIS MEANS FOR YOU: This study examined physical activity and sedentary behavior in assisted living residents and their relationship with a variety of outcomes. Participants included 54 residents from 8 communities, who had an average of 253 minutes of physical activity per day and 661 minutes of sedentary behavior per day. Depression related to lower activity, while use of assistive devices and fatigue related to higher sedentary behavior.

Physical Activity and Sedentary Behavior of Residents in Assisted Living: A Preliminary Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined physical activity and sedentary behavior in assisted living residents and their relationship with a variety of outcomes. Participants included 54 residents from 8 communities, who had an average of 253 minutes of physical activity per day and 661 minutes of sedentary behavior per day. Depression related to lower activity, while use of assistive devices and fatigue related to higher sedentary behavior.

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.

Replication of Implementing a Sit-to-Stand Exercise Program in an Assisted Living Facility

Mar 1, 2022
WHAT THIS MEANS FOR YOU: A 20-bed AL community in rural North Carolina implemented a sit-to-stand exercise program (i.e., having residents rise from a sitting position and then sit back down). A total of 13 residents participated in the program which was offered twice daily over 82 days. The average attendance rate for participants for all sessions was over 90%, and each participant was able to complete all 5 exercises during each session. Over the course of the program participants saw modest increases in average activities of daily living independence scores; however, these changes were not statistically significant. Activities that were measured included toileting, bathing, dressing, transferring, and continence.

Replication of Implementing a Sit-to-Stand Exercise Program in an Assisted Living Facility

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A 20-bed AL community in rural North Carolina implemented a sit-to-stand exercise program (i.e., having residents rise from a sitting position and then sit back down). A total of 13 residents participated in the program which was offered twice daily over 82 days. The average attendance rate for participants for all sessions was over 90%, and each participant was able to complete all 5 exercises during each session. Over the course of the program participants saw modest increases in average activities of daily living independence scores; however, these changes were not statistically significant. Activities that were measured included toileting, bathing, dressing, transferring, and continence.

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.

“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.

Psychotropic and Pain Medication Use in Nursing Homes and Assisted Living Facilities during COVID-19

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study focused on the potential impact of COVID-19 on the prescription of psychotropic and pain medication in nursing homes and assisted living. Nationally, there was relatively no change in the use of psychotropic and pain medications between pre- and post-COVID periods. However, there was increased use among individuals newly admitted during the pandemic, the cause of which was uncertain.

Psychotropic and Pain Medication Use in Nursing Homes and Assisted Living Facilities during COVID-19

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study focused on the potential impact of COVID-19 on the prescription of psychotropic and pain medication in nursing homes and assisted living. Nationally, there was relatively no change in the use of psychotropic and pain medications between pre- and post-COVID periods. However, there was increased use among individuals newly admitted during the pandemic, the cause of which was uncertain.

Monitoring Laboratory Parameters for Drug Toxicity in Assisted Living Facilities

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This quality improvement project focused on performing recommended laboratory tests per FDA medication labeling in a 58-bed assisted living community. Before the project, almost 60% of resident records had gaps in lab monitoring of medications, which was worsened because of COVID-19 restrictions. The project focused on close provider collaboration to ensure labs were conducted; after the project, almost 90% of residents received necessary lab tests for their medications.

Monitoring Laboratory Parameters for Drug Toxicity in Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This quality improvement project focused on performing recommended laboratory tests per FDA medication labeling in a 58-bed assisted living community. Before the project, almost 60% of resident records had gaps in lab monitoring of medications, which was worsened because of COVID-19 restrictions. The project focused on close provider collaboration to ensure labs were conducted; after the project, almost 90% of residents received necessary lab tests for their medications.

“What Keeps Me Awake at Night”: Assisted Living Administrator Responses to COVID-19

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study assessed how the early COVID-19 pandemic (Feb-Aug 2020) affected 40 assisted living administrators in Oregon. Three resulting themes from the interviews were emotion and burnout management (e.g., monitoring staff reactions), information management (e.g., monitoring latest recommendations and safety protocols), and crisis management (e.g., decision-making, emergency planning).

“What Keeps Me Awake at Night”: Assisted Living Administrator Responses to COVID-19

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study assessed how the early COVID-19 pandemic (Feb-Aug 2020) affected 40 assisted living administrators in Oregon. Three resulting themes from the interviews were emotion and burnout management (e.g., monitoring staff reactions), information management (e.g., monitoring latest recommendations and safety protocols), and crisis management (e.g., decision-making, emergency planning).

Factors Associated With Assisted Living Facility Closure

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study analyzed almost 2,000 Florida assisted living communities to understand factors related to assisted living closure between 2013-2015. During this time, 7.3% of communities closed; those with increased odds of closing had fewer beds, did not accept Medicaid, and had more regulatory deficiencies.

Factors Associated With Assisted Living Facility Closure

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study analyzed almost 2,000 Florida assisted living communities to understand factors related to assisted living closure between 2013-2015. During this time, 7.3% of communities closed; those with increased odds of closing had fewer beds, did not accept Medicaid, and had more regulatory deficiencies.

Staff Reports of Behavioral Expressions of Persons with Dementia in 250 Assisted Living Communities 

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study included health care supervisors from 250 assisted living communities in 7 states to understand how staff respond to behavioral expressions of residents with dementia. The most commonly reported expressions were combativeness and anxiety. A thematic analysis found that in about 25% of cases, staff recognized the events preceding behavioral expressions (antecedents). Staff in smaller and memory-care only communities were more adept at identifying antecedents; additional training to anticipate expressions may help prevent them.

Staff Reports of Behavioral Expressions of Persons with Dementia in 250 Assisted Living Communities 

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study included health care supervisors from 250 assisted living communities in 7 states to understand how staff respond to behavioral expressions of residents with dementia. The most commonly reported expressions were combativeness and anxiety. A thematic analysis found that in about 25% of cases, staff recognized the events preceding behavioral expressions (antecedents). Staff in smaller and memory-care only communities were more adept at identifying antecedents; additional training to anticipate expressions may help prevent them.

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.

Impact of Function-Focused Care on Psychotropic Medications and Opioid Use among Assisted Living Residents

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study evaluated the impact of function focused care (which trains staff to evaluate residents’ functional capacity and physical activity to optimize their participation in activities) on the use of psychotropic medications and opioids. The study observed 794 residents across 85 communities over 12 months. There was a reduction in opioid use in the treatment group after four months; in the full sample during the overall study period, there was an increase in the use of benzodiazepines and antipsychotics.

Impact of Function-Focused Care on Psychotropic Medications and Opioid Use among Assisted Living Residents

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study evaluated the impact of function focused care (which trains staff to evaluate residents’ functional capacity and physical activity to optimize their participation in activities) on the use of psychotropic medications and opioids. The study observed 794 residents across 85 communities over 12 months. There was a reduction in opioid use in the treatment group after four months; in the full sample during the overall study period, there was an increase in the use of benzodiazepines and antipsychotics.