Clinical Question

Do nursing homes improve the quality of life (QOL) in older persons with dementia?

Evidence-Based Answer

There is no “gold standard” to measure the QOL in older persons with dementia. For those requiring increased care, nursing homes may offer some benefit, including more frequent physician assessment and treatment of pain and depression, compared with assisted living/residential care facilities. Generally, patients living in assisted living/residential care facilities have better social functioning, less cognitive impairment, fewer comorbidities, and are more likely to receive medication for dementia compared with nursing home residents. However, evidence suggests a gradual decline in average functioning in persons with dementia, regardless of living situation. (Strength of Recommendation: B; based on cohort studies).

Evidence Summary

A large, multistate study highlighted the difficulties of determining QOL in the older persons with dementia living in assisted living/residential care facilities and nursing homes. The study examined 421 residents in 45 facilities in four states, and used six measures of QOL identified by the Alzheimer's Association, including depression, behavior symptoms, mobility, pain, food and fluid intake, and activity involvement. The authors conducted a series of observations and interviews with the resident, family members, and care-giving team.¹ This led to the development of recommendations by the Alzheimer's Association on these key issues to QOL.^1,2

Neuropsychiatric and behavioral symptoms related to dementia (defined as verbal, vocal, or motor activities considered to be aggressive, excessive, or lacking adherence to social standards) did not vary by facility type or characteristics.^3,4 Mobility limitation was nearly ubiquitous in the survey population, and similar proportions were noted in both types of facilities.⁵ In one study, cholinesterase inhibitors were used more often in residents of assisted living/residential care facilities than residents of nursing homes (35.1 versus 18.7 percent; P = .015).³ Such agents may benefit persons with mild dementia because they have the potential to postpone the need for skilled nursing home care.

Patients in assisted living/residential care facilities were less likely than patients in nursing homes to have intakes of less than 75 percent of their meal (50.4 versus 61.8 percent, respectively; P = .046) and fluid intakes of less than 8 oz (45.8 versus 63.4 percent, respectively; P = .011), especially if the residents were monitored in a public dining area (96.7 versus 81.5 percent, respectively; P = .038).⁶ However, residents of nursing homes were more likely to be assessed and treated by physicians for pain (58.9 versus 34.4 percent; P = .008)⁷ and depression (26.5 versus 15.2 percent; P = .015) compared with residents of assisted living/residential care facilities.⁸

One longitudinal cohort study showed that persons in assisted living/residential care facilities (at baseline) had statistically significant better social function on a 17-item scale of social functioning than those in nursing homes (5.1 versus 4.2 activities in the previous seven days, respectively; P = .001), had less severe cognitive impairment (5.3 versus 5.7, respectively, on the Minimum Data Set Cognitive Scale; P = .005), and had fewer comorbid conditions (3.6 versus 4.4, respectively; P = .001) or impairments of activities of daily living (7.6 versus 11.9, respectively; P = .001). The mortality and incidence of new or worsening morbidity showed little adjusted difference between the two settings, but residents of assisted living/residential care facilities had a significantly higher hospitalization rate than residents of nursing homes (69 versus 42 percent, respectively; P = .009). This finding is likely multifactorial in origin, resulting from factors such as less frequent physician visits and lack of skilled nursing care that is not usually available in assisted living/residential care facilities. It also could be a result of nursing home patient preference to avoid hospitalization compared with more functional assisted care/residential living patients. Overall, 25 percent of hospitalized assisted living/residential care patients ultimately require transfer to a nursing home. Although assisted living/residential care facilities are appropriate for residents with dementia who are medically stable and more mobile, those who are medically unstable require greater attention (like that provided in a nursing home).⁹

One study comparing persons with dementia in assisted living/residential care facilities and nursing homes found a small but statistically significant decrease in overall QOL, regardless of living situation, that could not be explained by demographics.¹⁰ The clinical impact of this is unclear, because in a longitudinal cohort study of 47 persons with dementia living in a long-term care facility, a substantial number of persons with dementia, including those with advanced dementia, did not experience this decrease in QOL. In fact, approximately one third to one half showed improvement in serial measures.¹¹

Recommendations from Others

There is no general consensus for or against institutionalization of patients with dementia. The Alzheimer's Association has issued a set of dementia care practice recommendations for nursing homes and assisted living/residential care facilities based on the information above. These recommendations do not support placement in one type of facility or another; but rather, they support improvement of dementia care in all facilities.² These recommendations are endorsed by many organizations, including the American Association of Retired Persons and the American Health Care Association.²

Clinical Commentary

The decision to move an older person out of his or her home is always difficult. The loss of independence and privacy is deeply grieved by many older adults and appears to be uniformly associated with declining function. For all the emotional appeal of the family home, it is encouraging to note that current evidence suggests that nursing homes are also a reasonable alternative and may indeed be a better choice for selected patients.