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Residential Care of Persons with Alzheimer's Disease (Dementia)

Jonathan M. Evans M.D. Mayo Clinic

Introduction

Our society is aging. The social and economic consequences of this have yet to be fully appreciated, however, the increasing demands this places upon our health care system have already been felt for some time. The population of Americans 65 years of age and older currently numbers almost 35 million and represents 13% of the total US population. This number is projected to grow by 40% in the next 30 years, and the number of persons who are 85 years of age and older will grow 80% over the same time period. As we age, the likelihood that we will need assistance in performing basic activities of daily living such as bathing, dressing and feeding ourselves increases exponentially.

Currently, there are almost 2 million Americans living in nearly 20,000 nursing homes at an annual cost of $53 billion. By 2030, 5 million Americans are expected to require nursing home care at a cost of $700 billion or more each year. Nevertheless, despite this enormous need for care, nursing homes in general do not enjoy a very positive image in our society. Perhaps it is because they represent frailty, dependence, old age and impending death. But even among seniors, a recent survey indicated that a substantial number of older Americans (aged 65 and over), most of whom have seen firsthand the inside of a nursing home, “would rather die than live in a nursing home.” The need for care is not going away, but the desire for alternatives to nursing home care is growing at least as rapidly as that need.

Most nursing homes in this country were built with a different population in mind than the population that currently lives in them. The current health care financial environment is driving changes now and will continue to do so in the near future. When they were originally built, most nursing homes were intended to house cognitively intact but medically ill individuals who would convalesce there in hopes of ultimately returning home. As a result, most nursing homes resemble hospitals, with high, hospital-style beds, long corridors and visibly prominent nursing stations. Over the last 25 years, however, nursing homes have become home to a million or more individuals with dementia and related conditions, requiring 24-hour supervision and “custodial” care.

Almost two thirds of all nursing home residents are cognitively impaired and, overall, the prevalence of mental disorders, (including dementia, delirium and psychiatric illness), among nursing home residents is over 90 percent. These buildings were, unfortunately, never intended to house these individuals. The physical plant was tailored to an entirely different purpose. As a result, these elderly nursing home residents often have difficulty conforming to the nursing home environment and their illness puts them in contact with a number of environmental hazards. Crowded public areas, slippery floors, and dim lighting increase the risk of falls, while hard floors and high beds increase the risk of injury.

Recent economic and regulatory changes have led to an increasing demand for nursing home beds to accommodate medically ill patients transferred from acute care hospitals and to serve as an alternative to hospitalization for some managed care systems. Nursing homes themselves have sought to increase operating income by preferentially admitting patients in need of skilled care. These market forces have had the effect of displacing cognitively impaired but physically well individuals.

What, then, of the more than 4 million Americans with Alzheimer’s Disease and related conditions? Where should they live when they can no longer be cared for at home and when nursing homes are ill-suited to meet their needs or are unavailable?

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