Every 66 seconds, someone develops Alzheimer’s disease. Because of the baby boomer generation, this number will continue to rise significantly in the coming years (2016 Alzheimer’s Disease Facts and Figures). As a result, it is essential to consider memory impaired individuals when creating space; specifically, those spaces in which patients receive long term care. Though there are claims that a wide range of options exist for memory impaired assisted living, types of care can be easily sorted into three groups: home care, institution care, or for few select individuals, care in specialized communities known as dementia villages. While there is a spectrum of care for each of these categories, more often than not, the main stream option is a typical nursing home or assisted-living facility. The direct influence of traditional hospital typologies is evident in the layout of the building, and is in part due to the use of government funding (Day). Specialized dementia and Alzheimer’s care does exist in some cities, though generally memory units differ in patient demographic and programing, and not in the way that spaces are formed. The idea of a dementia village, an isolated community that encompasses all aspects of living and social life, has proved successful in increasing patient autonomy; however, such facilities often exist outside of the urban realm and are built on the foundation of imitation and replication. Through historical analysis of medical building typologies and formal investigation of spatial relationships, this thesis aims to explore the opportunities within built space that allow aging and memory-loss patients to feel comfort. By flipping the relationship between the private and public realms of the building, it is possible to generate increased social interaction, improving the overall quality of life of the patients. / 0 / SPK / specialcollections@tulane.edu

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The purpose of this study was to determine which archetypal settings independent living residents of facilities that provide assisted living need and expect in the private living spaces of assisted living residences. The researcher developed an Archetypal Place Concept for Assisted Living Private Dwellings, based on work by Spivak (1984), which included eight archetypal categories with four sub-categories each. This concept was then used as a tool to evaluate scale models of assisted living dwellings constructed by independent living residents of retirement communities that offer assisted living. Seventeen residents in four retirement communities in Southwest Virginia participated in the research. The findings revealed that sample members believed all eight archetypal categories should be included in assisted living private dwellings. However, the degree to which the archetypal categories should be developed in a dwelling varied depending on whether the sample members were familiar with large or small assisted living dwellings. The most popular combination of sub-categories for sample members familiar with large assisted living dwellings was: multiple rooms not shared by unrelated adults, with separate sleep and living areas; separate sleep areas out of the living room with a door; bathrooms with a toilet, sink, shower, vanity closet, and linen closet; food storage with cooking appliances; two built-in closets; windows facing one direction, some with an outdoor area; separate seating for living and dining out of the sleep area; and kitchenettes with a refrigerator, sink, and cooking appliances. The most popular combination of sub-categories for sample members familiar with large assisted living dwellings was: one room not shared; a sleep area not shared, with no separate living room; a bathroom with a toilet, sink and shower, tied with toile, sink, shower, vanity storage, and linen closet; food storage with no cooking appliances; two built-in closets; windows facing one direction; designated seating arrangement within sleep area; and no kitchen, possible food storage. It was concluded that assisted living facilities should include a variety of dwelling types to meet different people's needs. However, any assisted living dwelling should include all eight archetypal categories to allow residents to function more comfortably. / Master of Science

Late life relocation for the purpose of receiving care may be one of the more challenging transitions for older adults because of being uprooted from their long-time home and the perceived loss of independence. Of available supportive housing options for older adults, assisted living facilities are growing in popularity. A family life review intervention, with an older adult resident and a selected family member, was facilitated to support older adults transition to assisted living through mutual storytelling and acceptance. Sixteen dyads participated in one, ninety-minute family life review (FLR) session. A semi-structured follow up interview was conducted approximately one month later to explore the perspective of families on participating in FLR during a relocation transition. Emergent themes (e.g., raising emotions in families, seeing self in systems, and navigating the relocation transition) suggest that FLR facilitated positive connections and enhanced existing relationships, ameliorated older adults negative feelings, and promoted an acceptance of self and new family narratives. Participating in the FLR allowed dyads to reflect, during and after the session, on their resilience earlier in life and how this resilience prompted an easier recovery to some of the more challenging components of the relocation transition (e.g., relational challenges with decision making, disagreements with the ALF). Personal and relational factors including the older adults physical health status, mental health concerns (e.g., depression and loneliness), and family involvement and dynamics impacted families experience and openness during the FLR as well as their perspective of the overall intervention process. Avenues for future research and clinical implications include randomized control trials testing the effectiveness of FLR on relationship satisfaction, coping, decision-making, and individual outcomes (e.g., depression, loneliness, life satisfaction) and using family challenges as opportunities for reconciliation and promoting resilience. / Ph. D. / Older adults experience numerous late life transitions, such as retirement, grandparenhood, widowhood, and relocation. Relocation occurs when older adults move from their long-time home to another the home of a family member or to a retirement community, assisted living facility, or nursing home. Assisted living facilities, the fastest growing housing option for older adults in the United States, focus on supporting older adults’ independence and managing their care needs. When older adults move to assisted living they can feel unstable and alone, and desire the support of their family network. The goal of this project was to support the transition to assisted living through participation in a family life review. Family life review (FLR) is a structured tool, facilitated by a researcher or practitioner, aimed at storytelling and mutual reflection. Older adults who moved within the last six months to assisted living participated with a selected family member in one, ninety-minute FLR session. A follow up interview was conducted approximately one month later to learn more about how FLR can shape older adult and family adjustment to the facility, relationship, and perspective of future transitions. Families’ reflections during the follow up included believing the FLR provided new perspective, enhanced existing relationships, alleviated older adults’ negative feelings, and promoted self acceptance. Families were able to reflect on earlier life experiences and consider their own strength and resilience in light of the current transition. Yet, health concerns (e.g., physical mobility) and relationship dynamics (e.g., disagreements about relocation decision-making) linked to how open families were in the FLR and how they were adjusting during the relocation transition. Findings from this research can be used with older adults moving to assisted living to support their desired level of family contact during the relocation transition and lifelong story to aid in their acceptance and adjustment to assisted living.

Master of Landscape Architecture / Department of Landscape Architecture/Regional and Community Planning / Hyung Jin Kim / The senior population within the United States has increased by 1.5% from 2010-2014, whereas other demographics have either stayed the same or have decreased (US Census Bureau, 2014). Assisted living facilities focus on sustaining and enhancing the quality of life for the residents, and their physical and social environments should be modified to stimulate this focus. Studies have shown that is can be accomplished by increasing access to nature. Additionally, a diminished physical activity level among senior citizens is an additional research problem as it contributes to their quality of life. With these research problems in mind, the two research question being addresses are: How does access to nature affect physical activity levels of senior citizens living within assisted living facilities; and how can indoor and outdoor landscapes assist in promoting physical activity? To answer the research questions, the following aims were established in support of the research and design objectives of this study: (1) identify barriers limiting use, and (2) idenify how access to nature affects phyisical activity levels in senior citizens within assisted living facilities, (3) to improve access to nature, (4) to improve quality of outdoor spaces, and (5) to encourage outdoor activity. Research Methods include (a) focus group interviews and (b)an environmental audit to investigate user’s preferences of activities, existing access to nature, and barriers prohibiting the use of the natural environments, (c) literature analysis and research to identify relevant design strategies that have been used in similar studies, and in the design phase,this study synthesizes how design principals can be utilized to solve the identified issues. The findings were then used to create a matrix for design and to also develop design goals and solutions for Homestead. The result of this study identifies strategies used to overcome barriers limiting outdoor use. The focus group and staff interviews along with the environmental audit and the literature analysis findings were used for developing a framework for design. The design framework and research methods this study used could be applied at similar facilities based on the ability ranges of the residents to produce a design solution that encourages outdoor use and physical activity, and thus, enhance the quality of life of the residents in the assisted living facilities.

Direct care worker turnover and shortages plague long-term care, weakening its quality, heightening costs for governments and employers, and cyclically breeding further turnover and shortages of workers. To address these issues, I investigate why direct care workers chose employment in long-term care (LTC), assisted living (AL) and specific AL facilities. Data come from a mixed-methods study of 45 AL facilities in Georgia, including interviews with 400 direct care workers. Findings include qualitative data analyzed using a grounded theory approach and descriptive quantitative data. Care workers’ motivations for employment in LTC, AL, and specific AL facilities reflect a split between moral and material values for care work, and care workers’ motivations illustrate a process of reconciling moral and material values. Individuals become care workers for reasons that are both materialistic, like earning a living wage, and moralistic, like the desire to care for others. They take employment expecting it to be consistent with their moral ideals and to satisfy their economic needs. Various individual, facility, industry, and community level factors influence workers’ motivations, and these factors reinforce the inconsistency between moral and material values for care work. Considering the heightening demand for LTC and short supply of care workers, as well as the deindustrialization of the economy, several recommendations are made for policies and practices that would support workers’ motivations for employment in LTC. Areas for future research also are highlighted.

Women outnumber men in assisted living (AL). This gender imbalance promotes the feminization of AL settings and affects men’s social experiences, particularly their co-resident relationships. AL research connects peer relationships to resident well-being and suggests gender that influences co-resident interactions. Yet, few studies have specifically examined men’s social experiences in AL. This analysis aimed to: (1) learn how men experience co-resident relationships in AL; and (2) identify the factors shaping these peer relationships. The analysis utilized qualitative data collected from two AL settings. Data collection involved participant observation and informal and formal in-depth interviews. Analysis was informed by principles of Grounded Theory Method and shows high variability in men’s co-resident connections. A range of individual- and facility-level factors promoted or constrained relationship development. Gender remains pivotal in structuring men’s social engagements. Individual- and facility-level factors often intersected with gender and influenced men’s social lives. Ultimately, co-resident relationships are consequential for men in AL.

This dissertation is a narrative inquiry of the ways in which cultural values, norms, and expectations shape the aging experience of elderly adults living independently in Kasson, a small rural town in southeastern Minnesota, and within Prairie Meadows, Kasson's residential assisted living facility. Despite significant evidence of the reciprocal relationship between community connectedness, successful aging, and healthy communities, we know relatively little about the ways in which contextual meanings of old age influence long-term care and perceptions of well-being in late life. I therefore utilized a variety of interpretive methods, including participant observation, textual analysis, in-depth interviews, and photovoice, to complement and enlarge existing research. Ultimately, I engaged crystallization methodology to co-construct with my participants a multivocal, multigenre text of layered accounts, photographs, stories, and personal reflections. My research design and presentation highlight the inherent possibilities of participatory methods, aesthetic ways of knowing, and asset-based community development for influencing policy and practice at individual, community, and societal levels with typically disenfranchised populations in future communication scholarship. My narrative analysis uncovered three overarching narratives - the "small town" narrative, the "aging in place" narrative, and the "old age" narrative - that guide communicative practices within and between Kasson and Prairie Meadows. Overall, elderly adults in these communities negotiate community connectedness in late life by drawing from or re-storying each of the three narratives. First, they co-construct personal and relational identities through social interactions and shared understandings (e.g., civic engagement, church membership, neighborliness, collective history) of what it means to live in a small town. Second, they face uncertainty (e.g., health and dependency issues) by turning to the past to make sense of the present and future. Third, they embrace old age through membership in age-specific contexts (e.g., Red Hats, senior center, Prairie Meadows) while resisting it in others (e.g., tensions between independence, isolation, and communal life). In total, their stories illuminate the ways in which personal meanings and cultural ideologies support and constrain interactions and decisions in late life as individuals strive for long-term living and a meaningful, supportive place in which to grow old.

Medication management is among the most commonly cited reasons for moving to assisted living and is closely associated with resident quality of life. Yet, the issue has received little research attention. Using data from the state-wide study, “Job Satisfaction and Retention of Direct Care Staff in Assisted Living”, this thesis examines medication management practices and accompanying regulations across 45 facilities in Georgia. A combination of quantitative and qualitative analyses is used to examine surveys with 370 direct care workers (DCWs) and in-depth, qualitative interviews with 41 DCWs and 44 administrators. Findings suggest that medication practices are not uniform and vary across settings and frequently, within facilities, in some cases violating regulations. Facility size, administrative philosophy, staff training and backgrounds, resident frailty, communication between staff, and ambiguous regulations, influence medication management. Future improvement will depend on clarifying and modifying existing regulations in ways that are achievable in practice and protect residents’ rights.

It is estimated that by 2050 the proportion of older adults in the U.S. will reach 20% (U.S. Census Bureau, 2008). This increase in the elderly population will likely be associated with a greater need for supportive services in various sectors, including healthcare and housing, such as assisted living communities. Many older adults choose to reside in assisted living communities due to increased difficulty managing health conditions or performing activities of daily living (e.g., bathing, toileting, walking). A primary goal of assisted living communities is to help residents maintain their health and well-being. However, little is known about how caregiving staff detect and interpret relevant cues, and what behaviors are taken to address concerns about residents. In addition to investigating these questions, the role of experience in the job was examined by comparing workers with a relatively low level of experience (1 month-16 months) to those with a relatively high level of experience (3+ years). These questions were addressed using a Critical Incident Interview and a Scenario-based Interview. The cues discussed by participants were categorized as Cognitive, Physical, or Emotional in nature. Participants reacted with concern to most of the scenarios, although the ratings they assigned to indicate their level of concern showed a high level of variability across participants. The explanations participants generated for the various scenarios were classified as either general or specific, with the majority of explanations coded as specific. Specific explanations were primarily that the situation was the result of a Cognitive/Emotional/Social issue or a Physical health issue. Of the actions participants described taking to handle the scenarios, gathering and using information was discussed far more than any other action. Participants discussed needing information related to the resident, such as their health, current and recent state, and personal history, as well as elaboration of the cues that initiated the concern in the first place, such as how long the symptom had been present. Participants also discussed various types of knowledge that they used in their decision making process. The most frequently discussed type of knowledge was health conditions and symptoms. Lastly, the data from the current study did not generally reveal differences between the two levels of experience that were examined. A revised model of caregiver decision making and practical contributions are discussed.