Assisted living facilities (ALFs) are a relatively new type of housing for older adults, which provide variable levels of care in a dignified and homelike environment. ALFs fulfill the needs of older adults who are not able to live independently in their own homes but do not require the greater care provided in nursing homes. There is considerable variability among ALFs in terms of housing arrangements, services provided, social milieu, and cost.
Currently, assisted living is the fastest growing segment of the older adult housing industry. There are about 1 million ALF residents in the United States, and that number is expected to continue rising as the population ages.
Characteristics Of Assisted Living Facilities
One of the defining characteristics of assisted living is that it provides residents assistance with activities of daily living (ADLs). Residents can expect to receive at least two meals a day, basic housekeeping services, transportation, and 24-hour access to staff. In addition, most ALFs have activity programs and social events, although the attendance at these events is often quite low. Many of the extra services available to assisted living residents are provided for a fee. For example, many ALFs charge residents for pharmaceutical services, bathing, laundry services, and driving them to medical appointments. The menu of services allows residents to customize their care to fit their needs and limitations. Some care requirements may disqualify someone from living in an ALF. For example, some facilities do not accept people who have behavioral problems, dementia, or urinary incontinence or need help with transfers (e.g., bed to wheelchair). The lack of uniform policies and services stems form the fact that there is no federal regulation of the assisted living industry; rather, individual states are responsible for regulating ALFs.
Characteristics Of Assisted Living Residents
About 75% of residents are female, and a similar proportion of residents are unmarried. The average age of ALF residents is about 82 years. Many older adults move to ALFs after rehabilitating in a nursing home or hospital, but about half move there directly from their own homes. Most ALF residents have some health or mobility problem, which requires assistance with ADLs. In addition, it is rare for ALF residents to drive; therefore, the transportation services are important. Increasingly, many ALFs are caring for individuals with varying levels of cognitive impairment. Most residents stay in an ALF for several years.
The cost of living in an ALF is highly variable and depends on a number of factors, including geographic region, size of living space (e.g., studio or apartment), extra services, availability of nursing staff, and overall quality of the facility. Most ALF residents use private funds to pay $1900 to $3500 rent on a monthly basis. Clearly, the cost of most ALFs is prohibitive for lower and some middle-income older adults. However, many ALFs are now accepting residents who are on public assistance (e.g., Medicaid), and many older adults will “spend down” their savings in order to qualify for government assistance. The cost of high-quality ALFs often makes them available only to more affluent individuals.
There is an average of 50 residents per facility, but the number of residents varies from 12 to more than 100. Most assisted living units are private and designed for one person; however, most facilities also offer a limited number of rooms designed for The average ALF is relatively new and has nicely furnished and decorated common areas. ALFs have become an increasingly safe place to live because of handrails, specifically designed bathrooms, and nonslip floors. All ALFs have a common dining area, and most have other common areas (e.g., game rooms, sitting rooms, libraries, private dining rooms, and patios).
In most “stand alone” ALFs, the residents can vary the number of services they receive, but they cannot move to another area of the building to get more intensive nursing care. There are also multilevel retirement communities that can accommodate different levels of care. These multilevel campuses offer independent living options (e.g., condominium or cottage), assisted living, nursing home care, and sometimes memory wards for individuals with dementia. Some have called this approach “aging in place,” and it has the benefit of not requiring disruptive moves when someone needs additional care.
Most ALFs transport residents to medical appointments. In addition, most have either an on-site nurse or one that will make regular visits to the community. Although the physical needs of residents are generally being met in ALFs, a number of researchers are reporting evidence that suggest residents’ psychological needs are not being fully met.
Psychological Aspects Of Assisted Living
ALFs and the people who operate them generally do an excellent job of providing for residents’ physical needs. However, because the staff perform many ADLs for residents, many residents do not get the cognitive stimulation necessary to maintain good cognitive and memory abilities. Residents do not necessarily have to make and remember appointments, plan meals, plan social events, remember to take medication, clean, go shopping, or do many of the other daily activities that challenge the mind and exercise the brain. Given the recent evidence in favor of the “use it or lose it” theory of memory and aging, it is important that older adults get enough cognitive stimulation. Some ALF residents live an active life; however, many do not get enough stimulation, which can lead to memory problems and possibly an increased likelihood of developing depression. There is considerable variation in the quality and participation rates of activity programs in ALFs. Therefore, it is important to consider the social milieu of ALFs because that may be related to the likelihood of developing depressive symptoms and also the quality and quantity of cognitive stimulation that residents receive.
The transition from independent to assisted living can be difficult for some residents. Many residents have experienced numerous losses that affect the quality of their social support networks. For example, because most ALF residents no longer drive, they have lost some of their independence and ability to visit friends and family. The typical ALF resident has lost his or her spouse, many close friends, and family members. It is often difficult for ALF residents to meet other residents once they move into a facility, especially if they are living around people with very different levels of cognitive functioning. Poor social support, in addition to medical problems, can lead to depression among ALF residents. A recent survey found that 25% of ALF residents had significant depressive symptoms, which is lower than nursing home rates, but higher than community dwelling rates of depression. ALF residents with depression are 1.5 times more likely to move to a nursing home than are individuals without depression.
Depression among older adults can lead to impaired cognitive functioning, which can lead to a need for more intensive care. Another risk factor among some ALF residents is memory loss and cognitive decline. Dementia is one of the primary reasons ALF residents are forced to move to facilities that provide additional care. However, high-quality ALFs can help people stay mentally, physically, and socially active.
- Assisted Living Federation of America, http://www.alforg
- Consumer Consortium on Assisted Living, http://www.ccal.org
- Cummings, S. M. (2002). Predictors of psychological wellbeing among assisted living residents. Health and Social Work, 27(4), 293–302.
- Hawes, C., Rose, M., & Phillips, C. D. (1999). A national survey of assisted living for frail elderly. Washington, DC: U.S. Department of Health and Human Services and General Accounting Off
- National Center for Assisted Living, http://www.ncal.org
- Schonfeld, S. (2003). Behavior problems in assisted living facilities. Journal of Applied Gerontology, 22(4), 490–505.
- Watson, L. , Garrett, J. M., Sloane, P. D., Gruber-Baldini, A. L.,& Zimmerman, S. (2003). Depression in assisted living: Results from a four-state study. American Journal of Geriatric Psychiatry, 115, 534–542.
- Winningham, G., Anunsen, R. A., Hanson, L., Laux, L., Kaus, K., & Reifers, A. (2004). MemAerobics: A cognitive intervention to improve memory ability and reduce depression in older adults. Journal of Mental Health and Aging, 9(3), 183–192.
- Zimmerman, , Scott, A. C., Park, N. S., Hall, S. A., Wetherby, M. M., Gruber-Baldini, A. L., et al. (2003). Social engagement and its relationship to service provision in residential care and assisted living. Social Work Research,27(1), 6–18.