A m e r i c a n A c a d e m y o f N u r s i n g

AAN News & Opinion

314 VOLUME 48 • NUMBER 6 NURSING OUTLOOK

Coalition to Change Assisted Living Regulations Governing Special Units for Dementia Patients

Rosalee Yeaworth, PhD, RN, FAAN

Nursing homes, retirement villages,and assisted living facilities are

opening increasing numbers of specialcare units (SCUs) for persons withAlzheimer’s disease (AD) and relateddementias. SCUs for persons with ADoriginated in nursing homes, most ofwhich operated under skilled nursingregulations. The idea was that instead ofusing physical and chemical restraints onpersons with AD to keep them fromwandering and disturbing other patientsand their belongings, there would be a

locked unit or wing. There these personscould wander, preferably with outdooraccess. The SCU would have morecontrolled stimuli and planned activities.The staff would have special preparationin caring for persons with AD. Most ofthe new units are nicely decorated, havehomelike features, and allow persons tofurnish their room with their own belong-ings. Whereas these features are niceoptions, most are operated under assistedliving regulations which do not requirethat one licensed person be on a unit with

25 or more persons with middle-stage tolate–middle-stage dementia. Most personswith dementia are older and likely to betaking not only medications for dementialike Aricept or Cognex, but also Lasix,Lanoxin, Detrol, or Glyburide. Yet, underassisted living regulations, their medica-tions can be given by a medication aidewith 20 hours of training, supposedlyunder the direction of the person receivingthe drug, their family members, or thephysician who ordered the medication.(The source of supposed supervision is

A m e r i c a n A c a d e m y o f N u r s i n g

AAN News & Opinion

315NURSING OUTLOOK NOVEMBER/DECEMBER 2000

most unclear in many instances.) Assistedliving regulations require that pharmacistsvisit quarterly instead of monthly as in askilled facility. Most patients in SCUs fordementia have spatial perception andbalance difficulties that make them at riskfor falls. They have difficulties expressingwhat is bothering them when they havepain or discomfort. They may not recog-nize family members, so male and femaleresidents may seek comfort and affectionfrom each other. They often cannotremember who did what to or for them,whether they had a bath, or whether theyate and what they had to eat. Nevertheless,assisted living regulations state that“assisted living promotes resident self-direction and participation in decisionswhich emphasize independence…. Noassisted living facility shall admit or retain

an individual who requires complexnursing interventions or whose conditionor behavior is not stable or predictable.”Whereas many persons with early stage andearly middle stage AD may live in anassisted living facility, especially if they havea spouse living with them, assisted livingregulations do not fit for the specialcommunication and behavior managementtechniques, the supervising of medications,the staff training and management, and theongoing assessment of physical and mentalstatus needed. An RN with special prepara-tion and experience in caring for personswith dementia should have responsibilityfor such a unit. Licensed nursing personnelshould be on each shift. Without advocacyand change in the philosophy that ADpatients are “a priority” for increasing “occu-pancy and profit margins,” some of our

most vulnerable citizens are being placed insettings in which they are supposed to beusing judgment they no longer possess andmaking decisions they are no longer capableof making.

So what are the policy implications?Where do we begin to take action? Nursesmust forge strategic alliances with concernedfamilies and other organizations such as theAlzheimer’s Association and AmericanAssociation of Retired Persons (AARP) toprevent SCUs for persons with dementiafrom being operated under assisted livingregulations. Nurses must work to developregulations that are more appropriate forthe level of care required and to lobby forlegislation to enact them, and they mustwork with the Academy’s Expert Panel onAging to increase the awareness of thestakeholders of these issues. �