The numbers and proportion of elderly people living and dying in long-term-care settings, both nursing homes and other residential care, are increasing dramatically. The decade between 1980 and 1990 witnessed a 29 percent increase in the number of elderly people residing in nursing homes (U.S. Bureau of the Census, 1990), and the annual growth rate of residential care has been between 15 percent and 20 percent (National Center for Assisted Living, 1998).
These residential care settings are known by a multiplicity of names, including sheltered housing, domiciliary care, intermediate-care housing, adult foster care, congregate care, and assisted living. All are nonmedical, communitybased living arrangements that have the following characteristics: They arc not licensed as a nursing home; they house two or more unrelated adults; they provide room, board, and either twenty-four-hour supervision or protective oversight or personal care services in activities of daily living; and they can respond to unscheduled needs for assistance. These facilities are a top growth industry, and it is predicted that within ten years they will serve more elderly people than nursing homes do (Meyer, 1998; General Accounting Office, 1999).
THE NURSING HOME AS A CARE ENVIRONMENT
As the number of elderly people served in long-term-care settings has increased, so has the number of elders with Alzheimers disease and related disorders. Depending on the method of ascertainment, rates of residents who have dementia in nursing homes range from 25 percent to 74 percent (Hing, Sekscenski, and Strahan, 1989; Lair and Lefkowitz, 1990; Rovner et al., 19go; Krause and Altman, 1998). Of the nearly 11-56 million nursing home residents, 47.7 percent (746,000 persons) had an active diagnosis of dementia documented on the Minimum Data Set for Nursing Home Resident Assessment and Care Screening (MDS), a standardized reporting instrument in use in all federally certified nursing homes (US. Department of Health and Human Services, 1998).
Whether nursing homes actually provide optimal care for people with dementia is controversial. There are some clear benefits: twenty-four-hour supervision, emotional relief for families, safety and fewer restrictions for wanderers, and increased opportunities for social stimulation (U.S. Congress, Office of Technology Assessment, 1987). However, it is argued that the needs for medical and skilled nursing are minor for many residents with dementia until late in the disease process and that nursing home care has been associated with problems such as improper use of physical and chemical restraints, inadequate food and food service, and lack of proper therapies and has contributed to fictional decline by encouraging dependency (e.g., Institute of Medicine Committee on Nursing Home Regulations, 1986).
Special care. One alternative to traditional nursing home care for people with dementia has been what is called special dementia care provided within nursing homes. Special care units as treatment environments for the care of people with dementia were developed in response to the recognition that people with dementia had specific care needs. Also, the rise of other types of residential care facilities has affected nursing home census rates, thereby creating a market force for development of dementia programs in nursing homes (OrrRainey 1994).
In 1996, as many as 22 percent of all nursing homes had a special care unit (Teresi et al., 1998). These units arc thought to provide a superior treatment environment for people with dementia because they are purported to specially select@ train, and supervise their staff, to provide activities designed for the cognitively impaired, to involve the family in treatment, and to have a physical environment designed for the safety and segregation of people with dementia. However, these components of special care are not always actually in evidence, nor do they necessarily translate to better outcomes. …