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Abstract and Figures

Adult Day Service (ADS) centers offer a variety of services to meet the needs of older adults and their caregivers. During the last decade, ADS has received increased attention due to shifts in policy toward home and community-based services for an aging population. This article reviews the effectiveness of ADS from 2000 to the present, with particular attention given to caregiver and participant outcomes, health care utilization, and future directions in ADS research. Multiple databases were searched to identify relevant research and 61 articles were selected for review based on inclusion criteria. The results of this review emphasize the need to implement and test more specific interventions targeting the needs of the ADS population.
Content may be subject to copyright.
Journal of Applied Gerontology
2014, Vol. 33(2) 130 –163
© The Author(s) 2012
Reprints and permissions:
DOI: 10.1177/0733464812443308
Fields et al.Journal of Applied Gerontology
Manuscript received: October 07, 2011; final revision received: January 18, 2012;
accepted: February 28, 2012
1The Ohio State University, Columbus, Ohio, USA
Corresponding Author:
Noelle L. Fields, The Ohio State University, 1947 College Drive, Columbus, OH 43210, USA.
The Effectiveness
of Adult Day Services
for Older Adults:
A Review of
the Literature
From 2000 to 2011
Noelle L. Fields1,
Keith A. Anderson1,
and Holly Dabelko-Schoeny1
Adult Day Service (ADS) centers offer a variety of services to meet the needs
of older adults and their caregivers. During the last decade, ADS has received
increased attention due to shifts in policy toward home and community-based
services for an aging population. This article reviews the effectiveness of ADS
from 2000 to the present, with particular attention given to caregiver and
participant outcomes, health care utilization, and future directions in ADS
research. Multiple databases were searched to identify relevant research
and 61 articles were selected for review based on inclusion criteria. The results
of this review emphasize the need to implement and test more specific interven-
tions targeting the needs of the ADS population.
adult day services, adult day care, home and community-based services, long-term
care, literature review
Literature Review
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Fields et al. 131
The aging of the population raises a number of important questions for society,
not the least of which is, “How are we going to care for these older adults?” By
2050, it has been estimated that 27 million older adults in the United States will
require care and assistance in the home, community, or institution—almost a two-
fold increase since 2000 (Department of Health and Human Services [DHHS],
2003). Several indicators point toward the expansion of home and community-
based services (HCBS) as a possible answer to this care dilemma. Nursing homes
tend to be the most costly care option, estimated at over $6,000 per month, and
increasingly we are finding that the same level of care can be provided in the com-
munity at lower cost (MetLife, 2010a). As a result, the number of nursing home
beds has decreased by almost 10% in recent years (Feng et al., 2011). Assisted
living is typically not an option for the vast majority of older adults as Medicaid
coverage is limited in this setting and it is not currently covered by Medicare. The
preferences of older adults and their family members are also important to con-
sider. Overwhelmingly and not surprisingly older adults prefer to age in their own
homes and, if care is needed, prefer to have those services delivered in the home
or in community settings (AARP, 2000). Policymakers have recognized this trend
toward HCBS and several initiatives have emerged supporting this option, such as
the PACE model (Program of All-Inclusive Care for the Elderly) and the recent
CLASS Act (Community Living Assistance Services and Supports). This leads to
a second important question: “Are the services provided in the home and commu-
nity effective?” In this article, we review the recent research literature (2000-2011)
on the impact of one specific service platform within the HCBS network—adult
day services (ADS). This review will provide researchers with an understanding of
the current state of the literature and where future studies are needed and provide
practitioners and policymakers with a comprehensive view of whether and to what
degree the services provided in ADS are effective.
ADS support the health, nutritional, social, and daily living needs of adults with
functional limitations in a group setting during daytime hours. ADS also support
family caregivers by enabling them to remain in the workforce and receive respite
from caregiving responsibilities (National Adult Day Services Association
[NADSA], 2011). Beginning as outpatient services for psychiatric patients in the
1940s, ADS expanded into geriatric day hospital programs in the 1950s. ADS
gained traction during the de-institutional movement of the 1960s, and by the
1970s, it was estimated that almost 300 ADS centers were in existence in the
United States. In the 1980s, ADS received additional attention from the federal
government as a cost-effective “alternative” to nursing home care and Medicaid
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132 Journal of Applied Gerontology 33(2)
dollars became available to pay for ADS. It was estimated that the number of
ADS had grown to over 1,400 centers nationwide. The 1990s saw further expan-
sion of ADS and the introduction of national standards for the industry. By the
2000, there were an estimated 3,400 centers nationwide and Medicare demon-
stration programs were initiated to determine whether ADS could potentially
reduce government spending on long-term care (NADSA, 2011).
Currently, there are over 4,600 ADS centers in operation serving an estimated
260,000 participants and families. Funding is currently derived from a variety of
sources, the majority of which comes from Medicaid Home and Community-
Based Waiver Programs and the Veteran’s Administration (VA). In terms of the
participants, 69% of ADS participants are age 65 and older, 21% are age 41 to 64,
and 9% are age 40 and younger. Physical and cognitive disability levels are high
among the current ADS population. Over 40% of all ADS participants have some
form of physical disability, and dementia impacts approximately half of ADS
participants. Chronic disease is also prevalent. Approximately 46% of partici-
pants have hypertension, 34% have cardiovascular disease, and 31% have diabe-
tes. Levels of assistance with other activities of daily living (ADLs) and
instrumental activities of daily living (IADLs) are also high (toileting, 45%; medi-
cation management, 44%; bathing, 30%; ambulating, 18%; eating, 16%). On aver-
age, ADS participants remain enrolled for approximately 2 years. The primary
reasons for disenrollment include placement into a nursing home, death of the
participant, and mismatches between the services offered in ADS and the needs of
participants (MetLife, 2010b).
ADS centers offer a variety of services to meet the needs of participants and
their family members. “Usual care” provided by ADS most often includes ser-
vices that address ADLs, nursing and other medical needs, psychosocial care,
meals, and programs for caregiver well-being and support. For example, over 90%
of ADS centers provide assistance with walking, toileting, and meals, and over
50% provide assistance with bathing. Over 80% of centers offer blood pressure
monitoring, weight monitoring, medication management, and diabetes monitoring
and approximately half of centers offer medication injections, wound care, cath-
eter and colostomy care, and tube feeding. Most ADS centers (80%) employ
either a registered nurse or licensed practical nurse as a part of usual ADS staff-
ing. Almost half of ADS centers offer physical, occupational, and speech thera-
pies, and many offer targeted interventions to address chronic conditions such as
diabetes. Over 1 in 10 centers offer job training programs, and over 7% provide
sheltered workshops—important services for younger adults in ADS. Another
basic feature in ADS is recreational and social programming. Over 75% offer
music, art, and pet therapies, and over 70% offer intergenerational programming.
Caregiver support is also an important service offered in ADS, and most centers
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Fields et al. 133
provide educational programs and support groups for family caregivers in addi-
tion to the benefit of respite (MetLife, 2010b).
Early research (1975 to 2000) has yielded some insight into the impact of ADS
in three primary areas: improvement of participant’s health and well-being,
improvement of caregiver’s health and well-being, and delay in nursing home
placement (NHP) (for a detailed literature review, see Gaugler & Zarit, 2001).
Summarizing this literature regarding the first area, ADS appeared to be effective
in certain domains of participant well-being, particularly in terms of emotional
well-being (e.g., mood, morale) and satisfaction with services. However, ADS
did not appear to be effective in addressing physical functioning outcomes, such
as participant health, ADL dependency, and behavioral problems (typically
dementia-related). In terms of caregiver well-being, earlier research provided
some indication that ADS can have a positive impact when used regularly over
the course of time. Finally, earlier research does not support the notion that ADS
can delay institutionalization and may not serve as an alternative to NHP. In fact,
some ADS programs were found to act as stepping stones to institutionalization
as family members become more comfortable in handing over care responsibili-
ties to professionals. It is critical to note that there were a number of limitations
in this past body of literature. Many past studies of ADS were small scale and
used quasi-experimental designs. Additionally, the rapid evolution of ADS over
the past 10 years may limit the value of this early research in understanding the
impact of current programs on these outcomes. This certainly points toward the
importance of reviewing the current literature on ADS to determine whether
changes in ADS have resulted in the way that ADS impacts participants and their
family members.
Building upon the previous literature review (1975 to 2000; Gaugler & Zarit,
2001), this review focused on past research on the effectiveness of ADS from
2000 to the present. In traditional meta-analysis, researchers are able to system-
atically assess previous studies through quantitative statistical analysis of the
extracted data (Petitti, 2000). However, conducting a quantitative meta-analysis
was not possible for this review, as the level of knowledge is limited to mostly
quasi-experimental and cross-sectional study designs. Although this review is
not a meta-analysis, the best available evidence from the literature provides an
important update to the knowledge base in ADS outcomes. To ensure thorough-
ness and inclusiveness, several academic databases were used in the literature
search, including MedLine, AgeLine, Psychology and Behavioral Sciences
Collection, Social Work Abstracts, SOCIndex, and CINAHL. Google Scholar
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134 Journal of Applied Gerontology 33(2)
was also used to locate articles and reports published outside of academia or
published in foreign journals. The search terms adult day, adult day services,
adult day health care, respite services, community-based care, and community-
based long-term care were entered into each database. Only publications from
the year 2000 or later were included in this initial search. After removing dupli-
cate entries, these searches resulted in a combined 415 article and report
abstracts. A search on Google Scholar resulted in an additional 20 articles. The
following three inclusion criteria were then used by one of the researchers to
effectively cull these results to 172 abstracts: (1) peer-reviewed, (2) empirically
based (including quantitative and qualitative data), and (3) available in English
language. The use of these criteria excluded conceptual articles, government
reports (not peer-reviewed), unpublished dissertations and theses, and industry
reports (not peer-reviewed). During the next step, a fourth eligibility criterion
was applied to the abstracts: (4) focus on the effectiveness of ADS (limited to
participant and caregiver outcomes). To ensure quality control and reliability,
multiple reviewers independently determined whether the abstracts met the
fourth criterion (effectiveness of ADS). Since this review focused on the effec-
tiveness of ADS, abstracts that focused on utilization were also excluded. The
reviewers then reconvened to compare their independent results. Initial interre-
viewer agreement (i.e., reliability) on a random selection of 25 articles was rela-
tively high (88%). Of those articles where disagreement existed regarding the
fourth criterion, the reviewers discussed the item in question and reconciled their
differences until complete consensus was reached, resulting in 54 abstracts.
Following the retrieval of these studies, the researchers then hand-checked the
reference lists of each article as a final step to ensure inclusiveness. Any addi-
tional articles were then examined to determine if they met the aforementioned
criteria. This exhaustive process yielded a final sample of 61 articles.
The literature of the last 10 years on ADS can be represented by updating the
conceptual model from the 2001 literature review conducted by Gaugler and
Zarit for the Journal of Aging & Social Policy. Nineteen studies were included
in the final review related to caregiver outcomes, 39 related to participant out-
comes, and 10 related to ADS and healthcare utilization. Of the 61 total number
of studies, only 8 studies utilized a randomized control trial design. The remain-
ing studies used cross-sectional, longitudinal, or quasi-experimental methods to
examine outcomes in ADS (see Tables 1-3). ADS use, which includes caregiver
respite and interventions, and general attendance and specific interventions for
participants are expected to impact caregiver and participant well-being as well
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Fields et al. 135
Table 1. ADS and Caregiver Outcomes.
Author Year Design Outcomes NPertinent Findings
Bartfay & Bartfay 2011 Cross-
Quality of Life 62 Support Groups
Offered in ADS and
in the Community
Had Similar Positive
Effects for Dementia
Caregivers in Both
et al.
2002 Randomized
control trial
Caregiver burden 372 No significant changes
in any of the outcome
measures for
caregivers using ADS.
Colvez et al. 2002 Cross-
Health status;
322 ADS attendance was
associated with
significant reductions
in feelings of isolation
for dementia
Danner &
2010 Quasi-
Quality of life 35 The Best Friends
approach to dementia
care was associated
with slight, yet
nonsignificant gains
in quality of life for
Droes, Breebaart
et al.
2004 Quasi-
Burden; coping;
55 The support
intervention had a
significant positive
effect on dementia
caregivers’ feelings of
competence. No other
significant outcomes
related to well-being.
Gaugler et al. 2003a Quasi-
Stress; well-being 400 ADS attendance was
associated with
reductions in role
overload for dementia
Gaugler et al. 2003b Quasi-
Care hours and
400 ADS attendance was
associated with
decreases in behavior-
related care hours for
dementia caregivers
and decreases in
problem behaviors in
care recipients.
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136 Journal of Applied Gerontology 33(2)
Author Year Design Outcomes NPertinent Findings
Gaugler et al. 2005 Longitudinal Burden; well-
4,761 No demonstrable
significant benefits
from ADS attendance
in terms of dementia
caregiver burden and
Gitlin et al. 2006 Quasi-
Burden; well-
129 ADS Plus was associated
with significantly lower
levels of depressive
symptomology and
enhanced capacity to
care for caregivers.
Gramain &
2004 Quasi-
Burden; health;
300 ADS attendance was
associated with
significantly less
burden for dementia
caregivers who were
employed or who
cared for individuals
with moderate levels
of disability.
Måvall &
2007 Longitudinal Hours; burden;
51 Prolonged ADS
attendance was
associated with
significant reductions
in dementia caregiver
hours; however, ADS
did not benefit all
caregivers in the same
Mossello et al. 2008 Quasi-
60 ADS attendance
was associated
with decreases in
burden for dementia
Quayhagen et al. 2000 RCT Stress; well-being 103 ADS attendance was
associated with
significant decreases
in hostility for
dementia caregivers
and enhanced
communication and
emotional involvement
among spouses.
Table 1. (continued)
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Fields et al. 137
Author Year Design Outcomes NPertinent Findings
Schacke & Zank 2006 Quasi-
Stress 37 ADS attendance was
associated with
significant reductions
in dementia caregiver
stress related to family,
job, and caregiving
Sussman &
2009 Cross-sectional Burden 85 Higher frequency
of ADS use was
associated with
significantly lower
levels of dementia
caregiver burden.
Valadez et al. 2005 Cross-sectional Burden
15 Mexican American
caregivers reported
lower levels of
worry and guilt and
more time for their
families due to ADS
Warren et al. 2003 Longitudinal Quality of life;
burden; health
122 No significant changes
in any of the outcome
measures for
caregivers using ADS.
Zank & Schacke 2002 Quasi-
Burden; well-
being; conflict
42 No significant changes
in any of the outcome
measures for
caregivers using ADS.
Zarit et al. 2011 Longitudinal Stress 121 ADS attendance was
associated with
significant decreases
in dementia caregiver
Table 1. (continued)
as health care utilization. This current model differs from the 2001 model by
adding interventions under services caregivers receive and by distinguishing
simple attendance from other interventions for participants. Finally, the original
model included delaying NHP as one outcome area. More current research has
included other health care utilization measures such as re-hospitalization, and
this addition is noted in this updated model (see Figure 1).
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138 Journal of Applied Gerontology 33(2)
Table 2. ADS Participant Outcomes.
Author Year Design Outcomes NPertinent Findings
Baumgarten et al. 2002 Randomized
control trial
Mood, functional
372 ADS attendance did not
demonstrate a positive
impact on depression
and anxiety; no effect
on functional status.
Bruin et al. 2009 Cross-sectional Activities 30 Participants in Green
Farm programming
experienced higher
intensity, more
frequent activities.
Burns et al. 2004 Longitudinal Functional status,
9 Participants declined
in functioning after
transitioning to ADS
from a Veteran’s work
Cherry &
2005 Longitudinal Cognition, mood 15 Participants showed
gradual improvement
in space-retrieval tasks.
et al.
2006 Randomized
control trial
93 ADS participants in role-
identity intervention
had higher levels of
interest in activities
and greater self-
awareness than nursing
home participants.
et al.
2010 Quasi-
Well-being 43 Participants receiving
reported higher yet
nonsignificant levels
of purpose in life, self-
esteem, and perceived
physical health.
& King
2010 Cross-sectional Psychosocial
28 Importance of
social connection,
participation and
enjoyment with
improvement in
psychosocial well-
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Fields et al. 139
Author Year Design Outcomes NPertinent Findings
Danner &
2010 Quasi-
Quality of life 37 Participants in Best
Friends program
indicated some benefits
in quality of life.
Davis et al. 2005 Quasi-
10 No demonstrable
differences for ADS
Diener &
2005 Quasi-
Functional status 72 Participants in the fall
prevention program
demonstrated less falls
than control group.
Droes et al. 2000 Quasi-
56 Participants in the family
support program
showed positive effect
on total behavior
problems, degree of
inactivity, and nonsocial
Droes, Meiland
et al.
2004 Quasi-
Behavior, mood,
112 Participants in family
support groups
showed moderate
effects on total
behavioral problems,
large effect on
depressive behavior,
and moderate effect
on self-esteem.
Femia et al. 2007 Quasi-
Functional status
mood behavior
201 Participants within
the ADS group
demonstrated fewer
depressive symptoms
and agitated behaviors
on days when they
attended ADS.
Gigliotti et al. 2004 Quasi-
14 Participant affect was
more positive during
horticultural therapy
than during traditional
ADS activities.
Gigliotti & Jarrott 2005 Quasi-
48 Significant differences in
amount of time spent
actively engaged in
horticultural activities;
participants manifested
more positive affect
during horticultural
Table 2. (continued)
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140 Journal of Applied Gerontology 33(2)
Author Year Design Outcomes NPertinent Findings
Hageman &
2002 Quasi-
Functional status 26 Significant change
observed in fast-gait
time for participants in
the resistance training
Horowitz &
2004 Randomized
control trial
Functional status,
28 No significant differences
found between
participants in lifestyle
redesign program and
control group.
Ishizaki et al. 2002 Randomized
control trial
Cognition, mood 25 Participants in the
improvements in
Jarrott et al. 2002 Quasi-
9 Participants engaged in
horticultural therapy
for greater periods of
time than in non-
horticultural activities.
Jarrott & Gigliotti 2010 Randomized
control trial
Activity 129 Participants (5 nursing
homes and 3 ADS)
demonstrated higher
levels of active and
passive engagement
than the comparison
Jennings & Vance 2002 Quasi-
16 Participants in the music
therapy intervention
showed significant
reduction in negative
behaviors after
Judge et al. 2000 Quasi-
Engagement 19 Participants in
programs exhibited
greater amounts
of constructive
engagement and less
passive engagement
versus regular
Table 2. (continued)
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Fields et al. 141
Author Year Design Outcomes NPertinent Findings
Kanamori et al. 2001 Quasi-
27 Aggressiveness, anxiety,
and phobias reduced
within participants in
the Animal Assisted
Therapy group.
Malone et al. 2002 Quasi-
Functional status,
41 From admission to
discharge in ADS,
participants had
improvements in
mobility, balance,
and depression;
from admission to
3 months post-
discharge from ADS
participants had
improved depression
Mossello et al. 2008 Quasi-
Cognitive status 60 Behavioral and
symptoms were
decreased in the
ADS participants
compared to
participants only
using home health
care services.
Quayhagen et al. 2000 Randomized
control trial
103 No significant differences
for ADS par ticipants.
Rentz 2002 Quasi-
Affect state, self-
41 Participants in art-based
program worked
with more sustained
attention, experienced
pleasure during activity,
and verbalized positive
feelings about self.
Schmitt et al. 2010 Quasi-
quality of life
124 ADS attendance was
associated with
greater improvements
in some quality of
life domains than
participants in the
comparison group.
Table 2. (continued)
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142 Journal of Applied Gerontology 33(2)
Author Year Design Outcomes NPertinent Findings
Schols & van der
2006 Cross-sectional Problematic
37 Fewer behavioral
demonstrated by
participants in the
farm day care setting
than when attending
traditional ADS.
Skrajner & Camp 2007 Longitudinal Engagement,
28 Participants with
dementia can successful
lead a Montessori-
based reading activity;
positive engagement
for participants in
Svidén, Tham, &
2004 Cross-sectional Quality of life 24 Participants in social
day center model
of ADS perceived
better psychosocial
functioning than
participants in
rehabilitative model
of ADS.
Gutierrez, & de
2006 Cross-sectional Well-being
24 Participants perceived
a positive effect of
ADS on socialization,
health, and easing of
Vance & Porter 2001 Quasi-
15 Montessori-based
intervention provided
a moderate benefit on
cognition and behavior.
Vance & Johns 2002 Quasi-
15 Montessori-based
intervention positively
influenced cognition,
attention, and social
Washburn et al. 2001 Cross-sectional Quality of life 19 Nursing home residents
participating in a mixed
social ADS model
with traditional long-
term care reported
improvements in social
support and quality
of life.
Table 2. (continued)
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Fields et al. 143
Author Year Design Outcomes NPertinent Findings
Weintraub &
2007 Cross-sectional Well-being
13 Participants in
programming reported
positive emotional
experiences including
feeling of being needed.
Weintraub &
2009 Cross-sectional Well-being
13 Participants’ perceptions
of physical well-being
in intergenerational
programming varied
depending on the
degree to which they
were involved in the
IG program.
Woodhead, Zarit,
Rovine, &
2005 Longitudinal Behavior 94 Positive behaviors
increased over a
3-month period for
participants in a variety
of activities at ADS;
engaging activities
decreased restless
behavior problems.
Zank & Schacke 2002 Quasi-
Cognition, well-
83 ADS showed positive
effects on participants’
well-being and
dementia symptoms;
comparison group had
more significant health
declines than ADS
Table 2. (continued)
ADS and Caregiver Well-Being
In terms of outcomes related to caregiver well-being, the literature can be divided
into two categories—studies that examined the impact of ADS attendance
(respite), in general, and studies that examined the impact of specific interven-
tions in ADS settings. Given the diversity present in ADS programming, it is
difficult to determine whether the respite benefits of ADS impacted caregiver
well-being or whether the unspecified services offered by ADS impacted the
burden and stress of caregivers. Although most ADS centers provide caregiver-
specific services such as support groups and individual counseling, there is a
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144 Journal of Applied Gerontology 33(2)
Table 3. ADS and Health Care Utilization.
Author Year Design Outcomes NPertinent Findings
Cho et al. 2009 Quasi-
Nursing home
371 Significant
were found in
delay of NHP
by relationship
(daughters vs.
wives) and by
ADS use.
Droes, Breebaart
et al.
2004 Quasi-
NHP 55 Participation in the
Meeting Centres
Support Program
delayed NHP
compared with
ADS “as usual.
Gaugler et al. 2005 Longitudinal NHP 4,761 No demonstrable
benefits of ADS
in terms of
delaying NHP for
individuals with
Gaugler, Kane
et al.
2003 Longitudinal NHP 3,944 Dementia
caregivers who
used either low
or high amounts
of ADS were
significantly more
likely to use NHP
Gitlin et al. 2006 Quasi-
NHP 129 Caregivers using
ADS Plus
intervention had
significantly lower
rates of NHP.
Jones et al. 2011 Quasi-
ER visits
78 Use of ADS post-
acute services
was significantly
associated with
lower levels of
and ER visits
within 30 days of
ADS enrollment.
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Fields et al. 145
Author Year Design Outcomes NPertinent Findings
Lyons et al. 2000 Quasi-
NHP 305 Dementia
caregivers who
used ADS were
significantly more
likely to use NHP
than caregivers
who relied upon
themselves or
other family
McCann et al. 2005 Longitudinal NHP 298 Controlling for
disease severity
and caregiver
burden, risk of
NHP increased
with increased
use of ADS for
individuals with
Wattmo et al. 2011 Longitudinal NHP 880 Substantial increase
in the use of ADS
was a significant
predictor of
shorter time
to NHP for
individuals with
Wilson et al. 2007 Longitudinal NHP 432 Higher levels of
ADS significantly
reduced the
risk of NHP for
individuals with
dementia who
cognitive decline.
Table 3. (continued)
critical need for standardized definitions of ADS in order to more effectively and
rigorously evaluate ADS outcomes (Tarrant, 2010). Despite these limitations, the
recent literature does provide a general understanding of the effectiveness of
ADS for caregivers and the potential that ADS has as a platform for caregiver
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146 Journal of Applied Gerontology 33(2)
The majority of the studies since 2000 have focused on general ADS atten-
dance and caregiver well-being, rather than specific programs and interventions
offered through ADS. As indicated in Table 1, the studies were diverse in terms
of design, sample size, and analysis. In the one study to use a randomized con-
trolled trial design (N = 103), researchers compared “non-pharmacological treat-
ments” for individuals with dementia. ADS was considered a “treatment” along
with several others, including cognitive stimulation, counseling, and education.
The researchers found that caregivers in ADS experienced significantly lower
levels of hostility from their care recipient compared with caregivers in the other
treatment groups (Quayhagen et al., 2000). Hostility was considered to be a com-
ponent of emotional well-being in this study. A number of studies used quasi-
experimental designs, which provide some valuable insight, despite threats to
internal validity and limitations regarding causation. Using a relatively large
dataset of dementia caregivers (N = 400), Gaugler et al. (2003a, 2003b) found
that caregivers who used ADS spent less time addressing behavior problems in
care recipients than caregivers who did not use ADS. This was related to reduced
feelings of role overload, an important indicator of caregiver burden. In another
study using a quasi-experimental design and a fairly large European sample (N =
300), researchers found that employed caregivers and those caring for persons
with moderate levels of disability experienced significantly lower levels of care-
giver burden when ADS was used rather than traditional home care (Gramain &
Malavolti, 2004). Two smaller studies using quasi-experimental designs also
Figure 1. An Updated Conceptual Model of the Effectiveness of ADS (adapted
from Gaugler & Zarit, 2001).
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Fields et al. 147
found that ADS attendance was associated with significantly less caregiver bur-
den (Mossello et al., 2008) and stress related to family conflict and employment
(Schacke & Zank, 2006). Several studies that used cross-sectional approaches
further supported the findings that ADS attendance is associated with higher lev-
els of caregiver well-being (e.g., isolation, worry, guilt) and lower levels of care-
giver burden and stress (Colvez, Joel, Ponton-Sanchez, & Royer, 2002; Måvall &
Thorslund, 2007; Sussman & Regehr, 2009; Valadez, Lumadue, Gutierrez, & de
Vries-Kell, 2005). In a more recent study, Zarit et al. (2011) used a within-subject
withdrawal design to address the limitations of quasi-experimental and cross-
sectional approaches. These researchers found that ADS attendance was associ-
ated with decreased levels of stress for dementia caregivers and fewer behavior
and sleep problems in care recipients. Although certain studies failed to find sig-
nificant effects for ADS on caregiver well-being (Baumgarten, Lebel, Laprise,
Leclerc, & Quinn, 2002; Warren, Kerr, Smith, Godkin, & Schlam, 2003; Zank &
Schacke, 2002), these studies tended to be small in scale and had methodological
issues, such as the use of untested measures. While additional research is war-
ranted to understand why ADS might be effective, the studies presented here
demonstrate that ADS attendance and the general benefits provided by ADS (e.g.,
respite, basic programming) can lower caregiver burden and stress and contribute
to the overall well-being of caregivers, particularly for those caring for family
members with dementia.
Only a small group of studies over the past 10 years have examined the
effects of specific interventions and programs on the well-being of caregivers in
ADS. While such studies may speak more toward the effectiveness of the inter-
vention rather than ADS, per se, the studies do provide valuable insight into the
ability of ADS to serve as a platform for innovative approaches to care. In the
most rigorous and informative of these studies, Gitlin, Reever, Dennis, Mathieu,
and Hauck (2006) used a quasi-experimental approach (N = 129) to evaluate the
effects of ADS Plus, an intervention that combines “typical ADS” with care
management, supplemental education and training, and enhanced support for
caregivers. Compared with caregivers receiving only ADS services, ADS Plus
was associated with significantly lower levels of depressive symptoms in care-
givers and an enhanced capacity to manage challenging behaviors. Danner and
McGuire (2010) used a pre-post-test design (N = 35) to evaluate the impact of
the Best Friends approach to dementia care in ADS. This approach uses a person-
centered philosophy and special training for staff and volunteers. The researchers
found that the Best Friends approach in ADS was associated with slight gains in
overall quality of life for caregivers. Droes, Breebaart et al. (2004) examined the
effects of an integrated support program (e.g., supplemental support groups, edu-
cation, and counseling) on stress and coping for dementia caregivers and their
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care recipients. The results indicated that the support program had few signifi-
cant effects; however, caregivers did report significantly higher feelings of com-
petence compared to caregivers in ADS “as usual.” The final study used a
cross-sectional approach (N = 62) to compare the effects of support groups in
ADS with support groups in the community (Bartfay & Bartfay, 2011). The
researchers failed to find significant differences in the effects of support groups
between the settings. Caregivers in both groups experienced similar benefits.
Despite the small number of studies that have tested specific interventions in
ADS and limitations in sample sizes and design, it does appear that the congre-
gate nature of ADS could make it an appropriate and effective platform for the
delivery of interventions and programs. Moreover, the provision of interventions
in ADS may potentially be more efficient than in other community-based set-
tings (e.g., senior centers) because of the accessibility and availability of pro-
grams, services, and staff in ADS. For example, most ADS centers already
employ professionals such as nurses, social workers, and direct care staff that
could assist with and/or provide interventions to participants attending ADS.
Additionally, there are opportunities for group interventions in ADS as most
centers currently provide programs such as caregiver education and support
groups. However, more research is needed to support the rationale for ADS as a
unique milieu for participant and caregiver interventions.
ADS and Participant Well-Being
The literature as it relates to participant outcomes can be categorized by interven-
tions designed to address activity engagement/participation, cognition, behav-
iors, physical functioning, and overall well-being. As indicated in Table 2, the
diversity of purpose, design, and type of interventions makes it difficult to ascer-
tain the effectiveness of ADS on participant outcomes. However, the literature
does provide a starting place for understanding interventions in these settings and
future directions for ADS research.
Many studies over the past decade have examined the effectiveness of inter-
ventions related to activity engagement/participation in ADS. Among the most
recent is a quasi-experimental study of the effectiveness of a civic engagement
intervention with ADS participants (N = 43) conducted by Dabelko-Schoeny,
Anderson, and Spinks (2010). Participants receiving the intervention reported
higher, yet nonsignificant, levels of purpose in life, self-esteem, and perceived
physical health. However, when the intervention was removed significant
declines were reported in self-esteem and perceived physical health. Cohen-
Mansfield, Parpura-Gill, and Golander (2006) used a randomized controlled
study to examine the impact of interventions that incorporate a participant’s
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Fields et al. 149
self-identity (e.g., lifetime role, hobbies, important family members) with activi-
ties in ADS and nursing homes (N = 93). Researchers found that ADS partici-
pants reported higher self-identity awareness and demonstrated higher level of
interest in these activities than nursing home participants. A number of studies
have also explored the effect of horticulture therapy in ADS and have found posi-
tive effects on engagement for participants in these activities (Gigliotti & Jarrott,
2005; Gigliotti, Jarrott, & Yorgason, 2004; Jarrott, Kwack, & Relf, 2002). In the
largest of these studies (N = 129), Jarrott and Gigliotti (2010) found that partici-
pants in the horticultural therapy treatment group demonstrated higher levels of
active and passive engagement than the comparison group. A small-scale analysis
(N = 30) conducted by Bruin et al. (2009) found that “green farm” programming
(e.g., feeding animals, cultivating vegetables) resulted in more intense, frequent
activities for ADS participants in these programs compared to regular day care
facilities. However, the results of these studies should be interpreted with caution
given a number of methodological issues, including small sample sizes.
In addition to the use of ADS as an effective “intervention” for dementia
(Cherry & Simmons-D’Gerolamo, 2005; Ishizaki et al., 2002), interventions such
as art-based programs (Rentz, 2000) and music therapy (Jennings & Vance, 2002)
have shown positive effects for cognitively impaired ADS participants. A number
of small-scale studies have also focused on the effectiveness of Montessori-based
programs in ADS. Judge, Camp, and Orsulic-Jeras (2000) used a pre-post test
design and found that compared with traditional ADS activities, participants in
the Montessori-based programs exhibited greater amounts of engagement.
Similarly, Vance and Porter (2001) and Vance and Johns (2002) found a moderate
benefit for ADS participants in Montessori programming, including a positive
influence on cognition. Skrajner and Camp (2007) also found engagement and
affect to be more positive among participants in Montessori-programming than in
standard ADS activities. Furthermore, several small studies have examined the
effectiveness of interventions designed to address various problematic behaviors
and have shown benefits for participants engaged in dementia-specific programs
(Danner & McGuire, 2010). A small, quasi-experimental pre-post test control
group study conducted by Droes, Meiland et al. (2004) found that dementia sup-
port groups showed moderate effects on behavior problems and large effect on
depressive behaviors (N = 112). These findings support earlier studies that found
a positive effect on the total number of behavior problems among participants in
the dementia support group compared to participants in the regular ADS pro-
gramming (Dröes, Breebaart, Ettema, van Tilburg, & Mellenbergh, 2000). In a
more recent quasi-experimental study, Mossello et al. (2008) found that behav-
ioral and psychological symptoms were significantly decreased in the ADS
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150 Journal of Applied Gerontology 33(2)
participants compared to participants only using home health care services.
Finally, Femia, Zarit, Stephens, and Greene (2007) explored whether ADS use was
associated with reductions in behavior and psychological symptoms of dementia
in a larger quasi-experimental study (N = 201). Findings suggested that within the
ADS group, behaviors such as agitation and symptoms of depression were lower
on days when participants attended ADS; however, there were no significant dif-
ferences between the experimental and control group (non-ADS users).
Several non-randomized quasi-intervention studies have examined the effec-
tiveness of interventions on the functional status of ADS participants including
falls (Diener & Mitchell, 2005), gait (Hageman & Thomas, 2005), and motor
skills (Davis, Hoppes, & Chesbro, 2005). Study findings suggest an overall posi-
tive impact of these interventions on ADS participants (e.g., less falls); however, it
is difficult to determine what fully accounts for these effects due to small sample
sizes. Other studies, such as Baumgarten et al. (2002), did not find demonstrable
effects of ADS on functional status compared to the waiting list comparison group
(N = 292). Similarly, in a small longitudinal study conducted by Burns, McCarten,
Adler, Bauer, & Kuskowski (2004), participants transitioning to ADS from a vet-
eran’s work program experienced functional declines. One of the few qualitative
studies of participant outcomes in ADS related to physical well-being was con-
ducted by Weintraub and Killian (2009). Through interviews with participants in
an intergenerational ADS center (N = 13), content analysis suggested that partici-
pants perceived that the impact of ADS on their physical well-being depended in
part on the degree to which they were involved with children at the center and
participated in the intergenerational programming.
Studies that investigate how ADS affects the overall wellness of participants
suggest that ADS attendance is associated with improvements in physical and
emotional problems (Schmitt, Sands, Weiss, Dowling, & Covinsky, 2010), per-
ceived psychosocial well-being (Dabelko-Schoeny & King, 2010), and positive
changes in social support and quality of life (Washburn, Luxenberg, Brod,
Steinhauer, & Katsap, 2001). Zank and Schacke (2002) conducted a quasi-
experimental study investigating the effects of ADS on well-being, health indi-
cators, and ADLs. Findings suggested that when compared to the untreated
control group, ADS participants experienced overall positive effects of day care
on their well-being and dementia symptoms. A qualitative study exploring par-
ticipant outcomes in ADS conducted by Valadez et al. (2005) found that social-
ization and social support from other ADS clients had a positive impact on the
physical and mental well-being of participants. Similarly, ADS participants in a
qualitative study of intergenerational programs reported overall positive experi-
ences and feelings of “being needed” (Weintraub & Killian, 2007).
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ADS and Health Care Utilization
Given the escalating financial costs of institutional care and the toll that institu-
tionalization can have on individuals and families, researchers have long explored
whether ADS could play a key role in delaying or preventing NHP. Findings from
research conducted prior to 2000 suggested that ADS does not appear to delay or
prevent NHP. Questions remain, however, as to whether institutionalization is a
valid measure of the effectiveness of ADS (Gaugler & Zarit, 2001). ADS may
serve as a valuable preparatory stage for moving into an institutional setting.
While the nursing home is generally not the preferred residence for most indi-
viduals and families, it may be the most appropriate setting for care when acuity
levels surpass the capacities of HCBS. In the current review, we move beyond
looking at the relationship between ADS and NHP and examine whether ADS use
can impact other types of service usage, most notably hospitalization rates. In
doing so, we begin to expand our understanding of the impact of ADS on health
care utilization, a topic of keen interest to health care policymakers.
As indicated in Table 3, 10 articles have been published that focused on ADS
and health care utilization since 2000, 9 of which used NHP as the outcome vari-
able. In two of these articles, Gaugler et al. (Gaugler., Kane, Kane, Clay, &
Newcomer, 2003; Gaugler, Kane, Kane, & Newcomer, 2005) used data from the
Medicare Alzheimer’s Disease Demonstration Evaluation (MADDE), a large,
multi-site study of the effectiveness of expanded community-based services
(including ADS) for individuals with dementia and their caregivers. In the earlier
of these two studies, the objective was to identify predictors of NHP over a 3-year
period for 3,944 older adults diagnosed with dementia. Interestingly, the findings
indicated that ADS usage had a curvilinear effect on NHP. Caregivers who used
either low or high amounts of ADS were 1.30 times more likely to institutionalize
sooner. It was concluded that there may be a dosage effect and caregivers who
used low amounts of ADS may not have used sufficient amounts of ADS to ben-
efit. Caregivers who used high amounts of ADS may have used these services as
a “stepping stone” to institutionalization. In the second study using the MADDE
dataset (N = 4,761 in this case), Gaugler et al. (2005) tried to determine whether
utilization of community-based services (including ADS) early in the dementia
caregiving process could delay NHP. Results revealed that there were no demon-
strable benefits from ADS attendance in terms of delaying NHP. The authors
noted, however, that ADS can be beneficial to caregivers and may delay NHP if
used in certain patterns.
Two sets of researchers drew upon data from the Adult Day Collaborative
Study (ADCCS), a quasi-experimental study that evaluated the effectiveness of
ADS on a number of outcomes, including time until NHP. In the first of these
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analyses, the researchers sought to determine if the pattern with which dementia
caregivers (N = 305) interface with informal help (e.g., family, friends) and for-
mal help (including ADS) impacted the decision to institutionalize care recipients
(Lyons, Zarit, & Townsend, 2000). Results indicated that caregivers who used
ADS more frequently were more likely to institutionalize compared with caregiv-
ers who relied on themselves only or on other family members. In the second
analysis, the researchers examined whether there were differences between daugh-
ter and wife dementia caregivers (N = 371) who used ADS in terms of their deci-
sion to institutionalize care recipients (Cho, Zarit, & Chiriboga, 2009). Findings
indicated that daughters who used ADS were more likely to postpone NHP than
daughters who did not use ADS. The researchers also found that wives using
ADS placed care recipients into nursing homes significantly sooner than daugh-
ters using ADS. These findings point toward the complexity of the decision to
place a family member into a nursing home and suggest that ADS use can play a
role in delaying NHP, particularly for adult children.
Three independent studies used primary longitudinal data to examine the rela-
tionship between ADS and NHP. The earliest of these studies focused on a sample
of older adults with dementia (N = 298), some of which were using ADS (McCann
et al., 2005). The researchers found that risk of NHP significantly increased with
increases in the number of days that care recipients attended ADS. These findings
remained significant after controlling for disease severity and caregiver burden. A
more recent study conducted with a Swedish sample of older adults with dementia
(N = 880) found similar results; increase in ADS use was a significant predictor of
shorter time to NHP (Wattmo, Wallin, Londos, & Minthon, 2011). Both sets of
researchers acknowledged that the rationales and factors related to NHP are com-
plex and that increased ADS use may be a last gasp attempt at keeping care recipi-
ents in the home. Running contrary to these findings, Wilson et al. (2007) found
that higher levels of ADS use substantially reduced the risk of NHP for older
adults experiencing accelerated cognitive decline (N = 432). These researchers
concluded that ADS may be used as a transitional stage between community and
institutional living.
The final two studies used quasi-experimental approaches to evaluate inter-
ventions in ADS compared with ADS services “as usual.” Gitlin et al. (2006)
evaluated the effects of ADS Plus, an approach that combines usual ADS services
with supplemental care management, support, and education. ADS Plus caregiv-
ers were found to use ADS services significantly more frequently and had a sig-
nificantly lower rate of NHP. Droes, Breebaart et al. (2004) evaluated a similar
integrated support program, the Meeting Centres Support Program, for individu-
als with dementia and their caregivers. The researchers found that participation in
the intervention was related to significant delays in NHP. While both of these
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interventions appear to be promising, replication and larger studies are needed
regarding both the effectiveness and feasibility of such interventions in ADS.
Physical and cognitive limitations as well as chronic disease are high among
the ADS population. The most prevalent medical needs among ADS participants
are dementia (47%), hypertension/high blood pressure (46%), and physical dis-
ability (42%) (MetLife, 2010b). Reflective of advances in the capacity of ADS to
serve complex medical needs (for detailed information, see the recent MetLife,
2010a), researchers have begun to look at the effectiveness of ADS to reduce
health care utilization, most notable emergency room visits and rehospitalization.
In a 2011 study, Jones et al. used a quasi-experimental, retrospective approach to
evaluate the impact of a pilot program for the provision of post-acute care in
ADS. Participants requiring post-acute services (N = 78) were discharged from
one hospital into either ADS or alternative destinations, including skilled nursing
facilities, home health, or home with outpatient services or self-care. Those who
participated in ADS services were significantly less likely to be readmitted to the
hospital or to visit the emergency department within 30 days following discharge.
The same effect was also evident within 90 days following discharge; however,
the differences did not reach levels of significance. There were limitations in this
study, especially in terms of sample size and the self-selection process.
Nonetheless, these findings point toward the potential effectiveness of ADS to
serve as an effective step down following hospitalization.
In looking at the effects of ADS on health care utilization, the picture is far
from clear. Reviews of research prior to 2000 concluded that ADS programs do
not consistently delay NHP and may, in actuality, “facilitate family members’
decisions to place” through a step-down process of relinquishing care (Gaugler &
Zarit, 2001). Research conducted since 2000 on “usual” services offered through
ADS appears to confirm this conclusion and further confirms that the decision to
place a family member into a nursing home is typically a complex process.
There are several limitations of this current review that are important to high-
light. Although the literature search included robust strategies such as the use of
three reviewers, multiple scholarly databases, and hand-checking the reference
list of articles, it is possible that smaller studies of ADS may have been missed.
The reviewers also chose to focus on peer-reviewed work, thereby excluding a
number of reports from agencies and groups. It was decided that the quality
control provided by the peer-review process outweighed the inclusion of such
work. There was also a degree of subjectivity in the selection and application of
the exclusion criteria. However, the researchers attempted to err on the side of
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154 Journal of Applied Gerontology 33(2)
inclusion in selecting the studies for subsequent stages of the review process. The
use of multiple reviewers also added a level of reliability in the selection process.
In terms of the methodology used in the current study, the researchers chose to
replicate the strategy of the previous review conducted in 2001 (Gaugler & Zarit,
2001). This was done for continuity and comparison purposes. As the body of
literature on the effectiveness of ADS continues to develop, more complex meth-
odologies can be employed, such as meta-analyses. This would allow for the
measure of effect size—a key to understanding the degree to which ADS impacts
the well-being of participants and family caregivers.
Future Directions
The studies on ADS since 2000 have primarily examined the impact of ADS
attendance or the effect of specific interventions that take place in an ADS set-
ting on participants and family caregivers. Many questions remain regarding
who ADS helps, how, and under what circumstances. The effectiveness of ADS
has been difficult to document for several methodological reasons. First, repli-
cation of previous studies has been a challenge due to the lack of a standardized
definition of ADS. What is the “intervention” that is being tested? Rather than
examining ADS as a generic service, it may be beneficial to examine specific
elements of ADS or interventions offered through ADS. Secondly, there is sig-
nificant variability in individual experiences within the same program. This may
be partially explained by the variability in ADS attendance, as weekly participa-
tion varies from 5 days a week (46%), 3 days a week (29%), 2 days per week
(19%), and other (7%) (MetLife, 2010b). Previous research suggests that a
minimum of 2 days of ADS services is needed for family caregivers to experi-
ence stress reduction and positive psychological benefits of ADS (Zarit,
Stephens, Townsend, & Greene, 1998). However, there is a lack of research that
specifies a “dosage” effect for ADS recipients. Thus, examining the actual “dos-
age” of ADS is very difficult as many studies vary in how participation in ADS
is measured. Furthermore, individualized care and a personalized care philoso-
phy leads to different participants within the same program receiving different
services. Many day programs serve few participants on average, about 57 per site
and only 34% attend daily (MetLife, 2010a). With inter- and intraprogram vari-
ability, gaining a sufficient sample size and participants receiving enough ser-
vices (dosage) within one program to detect an effect can be a challenge. Finally,
few studies employed randomized controlled designs. This limits the ability to
establish causal relationships given the inherent issues of internal validity in
quasi-experimental and cross-sectional designs. Given the ethical concerns of
randomly assigning individuals to ADS, this is a difficult limitation to overcome.
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Fields et al. 155
Despite these challenges, ADS can benefit caregivers through basic respite
and “typical” programming. These findings support the earlier ADS literature
examined by Gaugler and Zarit (2001). However, less is known about the impact
from the specific services adult day centers provide for family caregivers. Beyond
respite services, ADS provide educational programs (71%), support groups
(58%), and individual counseling (40%) for family caregivers (MetLife, 2010b).
Gitlin et al.’s (2006) study of “ADS plus” programs shows some promising
results in this area. Future studies that examine the impact of these and other
specific interventions that occur within an ADS setting may provide a more accu-
rate picture of what ADS programs do for caregivers and what impact those ser-
vices make on their quality of life. Zarit et al. (2011) is the first study to
systematically examine “carryover” effects of ADS and the impact day time
attendance has on evening behavior. This is an exciting area for future research.
Does daily attendance influence the well-being of participants and caregivers
while at home, not just in the care setting? Given that ADS often serves as a tran-
sitional stage between community-based and institutional care, future research
might also examine the association between prior ADS use and adjustment to
nursing home settings. Previous research suggests that increased use of ADS may
result in difficult family caregiver transitions after nursing home placement; how-
ever, more evidence is needed to better understand the relationship between ADS
and transitions to institutional settings (Nikzad-Terhune, Anderson, Newcomer,
& Gaugler, 2010). For instance, does previous experience with social and recre-
ational programming in ADS (e.g., group activities) impact residential relocation
to congregate housing? Future studies on the impact of ADS on caregivers also
need to take heed of Cho et al.’s (2009) approach of not treating all caregivers as
one homogenous group. Instead, they need to recognize that ADS may play dif-
ferent roles in supporting the well-being of adult children compared to spousal
caregivers. Finally, as ADS continue to rely on public reimbursement for ser-
vices, more attention will be placed on if and how ADS can support working
caregivers in terms of minimizing lost productivity and wages.
The impact of ADS on participants remains even less clear. The research in the
last 10 years seems to have moved away from examining the impact of ADS on
the physical functioning of participants, which was a theme found in the Gaugler
and Zarit (2001) review. As suggested by Gaugler and Zarit at that time, ADS
may have more of an impact on the emotional well-being of participants than
their physical functioning. This review supports that notion, though the studies
examined had a number of methodological issues. Studies that did demonstrate a
positive effect of ADS on participants were those that examined the impact of
ADS on participant engagement, psychosocial well-being, and problem behav-
iors (e.g., Schmitt et al., 2010). There are a few notable exceptions to these themes
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156 Journal of Applied Gerontology 33(2)
(e.g., Diener & Mitchell, 2005; Hageman & Thomas, 2002; Malone, Hill, &
Smith, 2002). These studies investigated the effectiveness of fall prevention
efforts within an ADS setting. Testing specific evidence-based interventions that
address costly chronic care conditions within ADS centers is a promising area of
future research. ADS are well positioned to be a platform for preventing and
treating chronic diseases and conditions such as dementia, diabetes, congestive
heart failure, and others. Additionally, the emergence of creative programs such
as the use of equine therapy for dementia, volunteer and civic engagement activi-
ties, and intergenerational partnerships with settings such as hospitals and univer-
sities points toward great opportunities for innovation in ADS.
Implementing and testing specific protocols targeting the needs of the ADS
population may result in a clearer picture of what works with whom under what
circumstances, and perhaps could demonstrate that ADS can help save health care
dollars. Furthermore, as the aging population becomes more diverse, more research
is needed to examine the role of race and ethnicity among ADS participants and
their caregivers. Despite the fact that approximately 40% of the ADS population
consists of people of color, we know little about the differential impact of ADS
based upon race/ethnicity. Additional research is needed to understand the potential
of ADS in meeting the changing demographics of the United States. Finally, the
cost of providing effective interventions should not be overlooked. The ADS indus-
try faces tremendous challenges in terms of remaining solvent and cost effective-
ness and efficiencies are a central concern within the industry (Anderson,
Dabelko-Schoeny, & Tarrant, in press). Cost effectiveness should be a central con-
sideration in the evaluation of overall effectiveness for any intervention in ADS.
Given the fiscal challenges we face in providing long-term care services for
individuals with disabilities, researchers continued to examine the ability of ADS
to prevent or delay more costly institutionalization. Gaugler and Zarit (2001)
argued that the inability to document this impact could have been the result of the
limited amount of services received (i.e., number of days attended) and/or the
limited number of individuals enrolled in studies that experienced the event of
interest (i.e., NHP). Work of the last 10 years seems to suggest that ADS actually
acts as a stepping stone to institutionalization for spousal caregivers but can pre-
vent or delay institutionalization when the primary caregiver is an adult child (see
Cho et al., 2009; McCann et al., 2005). New to the literature are efforts to exam-
ine the impact of ADS on other costly health care utilization including post-acute
care and rehospitalization (Jones et al., 2011). However, moving forward, the
question remains: What elements of the ADS experience make a difference? As
we search for strategies to address rising health care costs and ADS providers
continue to struggle with providing evidence regarding their value, more research
in this area is critically needed.
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Fields et al. 157
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or pub-
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Author Biographies
Noelle L. Fields, MSW, is a doctoral candidate and John A. Hartford Doctoral Fellow
in the College of Social Work at The Ohio State University. Prior to entering the
doctoral program, she was a clinical social worker and mental health practitioner in
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Fields et al. 163
long-term care settings. Her scholarship and research interests focus on transitions to
residential care settings and improving psychosocial service delivery in assisted
Keith A. Anderson, MSW, PhD, is assistant professor and John A. Hartford Faculty
Scholar in the College of Social Work at The Ohio State University. Prior to his cur-
rent position, he was a clinical social worker at The Washington Home, a nursing
home and hospice located in Washington, DC. His scholarship and research focus on
the well-being of older adults and their caregivers, understanding and improving
quality of life in long-term care settings, informal helping networks, and end-of-life
Holly Dabelko-Schoeny, MSW, PhD, is associate professor and John A. Hartford
Faculty Scholar in the College of Social Work at The Ohio State University. Her
practice and research interests focus on improving the delivery of community-based
services for older adults and their caregivers through collaboration with community
agencies, other faculty, and students. The overall purpose of her work is to improve
the well-being of older persons with cognitive and functional challenges living in the
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Full-text available
Background: Hospital stays that are prolonged due to non-clinical factors are costly to health care systems and are likely suboptimal for patient well-being. We assessed the influence of psychosocial factors on hospital length of stay (LOS) for older Canadians in a retrospective cohort study. Data and Methods: Data from the Canadian Community Health Survey were linked with the Discharge Abstract Database. Analyses were stratified by age, 55–64 ( n = 1,060) and 65 and older ( n = 2,718). Main predictor variables of interest included four measures of social support, sense of belonging, and living alone. Multivariate models of LOS adjusted for age, sex, income, smoking, and frailty. Results: Among the younger respondents, low positive social interactions, low emotional/informational support, and living alone were associated with a longer LOS. Among respondents 65 and older, low affection, low positive social interactions, low emotional/informational support, and a weak sense of belonging were associated with a longer LOS. Discussion: Having low social support is associated with longer hospital stays in this Canadian cohort. Social support may influence LOS as risk factors for poor health and precarious care in the community. Mitigating these risk factors could reduce the economic burden that is played out through longer hospital stays.
Our study aimed to explore the impact of different home‐ and community‐based service (HCBS) use patterns on older adults' physical function. The cohort data were drawn from two national datasets, the National Ten‐Year Long‐Term Care Plan 1.0 database and the National Health Insurance Program claims data. Participants were care recipients ages 65 and over, first evaluated and prescribed HCBS from 2010 through 2013 and evaluated again after 6 months (n = 32,392). Latent class analysis was used to identify subgroups with different HCBS use patterns. Multiple regression was used to examine the impact of different HCBS use patterns on change over time in disability related to activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The analysis was stratified by respondents' levels of disability. Four subgroups of HCBS recipients were identified, with patterns of home‐based personal care, home‐based personal care and medical care, home‐based medical care and community care services. Older adults in the Home‐based MpC had significantly more improvement in both ADL (p < 0.05) and IADL (p < 0.001) scores compared with adults in the other three groups, while the community care group regressed the most. In the stratified analysis of the severely disabled, the IADL outcome of the Home‐based MC group was better than the home‐based PC group (p < 0.001). Study findings shed light on the benefits of promoting the use of integrated HCBS that combines personal and medical care, especially for community care services.
Full-text available
Background: Social day centres can support active and healthy ageing amongst older people. However, little is known regarding the importance of social day centres. Aims/objectives: The aim of this study was to explore how older people visiting social day centres perceive the day centres' social influence on their health and well-being. Material and methods: Twenty older persons attending social day centres on a regular basis were interviewed regarding activities at the day centre and their importance for active and healthy ageing. The data were analysed using qualitative content analysis. Results: The social day centres were described as arenas to provide a structure (and something to do) in the visitor's everyday life. By attending a day centre, the participants created a social context with other visitors. Staff acted as facilitators for visitors, helping them to interact with other visitors and to experience the feeling of being needed by others. Conclusions: The findings suggest that social day centres are important arenas for creating a sense of context and belongingness amongst older people. Significance: This study provides knowledge on how doing and being contribute to healthy and active ageing.
Globally, day programs are increasingly proposed in policy as one way to address the support needs of people living at home with dementia and their families. Day programs represent a kind of space that can meet multiple interests and ideologies concerned with sustaining care at home for people living with dementia. In this paper, we draw on findings from an ethnographic study of how day programs work as care in the community for people living with dementia to argue that day programs’ ontological status in research as a “simple location” of care contributes to the ambiguous outcomes and limited evidence available for improving their design and delivery. Using one program as an illustrative case, we demonstrate the multiplicity of a day program and the ontological politics through which the potentialities for care emerge. Robert Cooper’s proximal analysis of organizing’s and Annemarie Mol’s work on ontological politics inform this analysis. Of note in this analysis are the different enactments of a day program and their modes of coordination. We show when these enactments hang together well and when they do not and consider the effects of these politics for care. Of particular concern is how some versions of a day program are easily displaced by the interests of administrative versions and managerial logics. We argue for approaches to research and planning that acknowledge the “day program multiple” and precarious nature of care.
Full-text available
Background and objectives: Although most studies have not separated turnover of direct care workers (DCWs) into those who switch to another organization (switchers) and those who leave the industry (leavers), switchers and leavers have different impacts on the facilities they quit and the labor market for DCWs. We distinguished between intent to switch and intent to leave and investigated the impact of wages and training on each turnover intention. Research design and methods: Data were obtained from Japan's Fact-Finding Survey on Long-term Care Work. We included DCWs (n = 7,311) in the analyses and used multinomial regression by sex and provider type to compare those who wanted to switch and those who wanted to leave with those who wanted to remain in their current workplace. Results: The impacts of an increase in wages and a higher training score were larger for intent to switch than intent to leave. Compared with wages, the impact of training was greater. The impact of job characteristics on turnover intention varied between women and men and across provider types. Discussion and implications: This study provides a better understanding of the difference in the determinants of switching and leaving and simultaneously increases our understanding of the differences between women and men and across provider types.
Background: Approximately one third of adults in adult day services (ADS) centers have Alzheimer's disease (AD) and AD-related dementias (ADRD). Understanding of the impact and effectiveness of ADS on persons living with dementia (PLWD) is limited by a lack of patient and caregiver relevant outcomes (PCRO) data. We identified PCROs collected at ADS sites in states that mandate serial data collection and examined the degree to which these data align with established Dementia Care Practice Recommendations (DCPR) and PCROs used in other areas of long-term care. Methods: We conducted an item analysis of regulatory forms used by ADS. Consistent with the methodology used by the Imbedded Pragmatic AD/ADRD Clinical Trials (IMPACT) Collaboratory for PCROs collected in other long-term care settings, we created a matrix informed by DCPR. We matched each item in regulatory forms reflecting a PCRO to one of the seven DCPR domains as well as to the 53 PCROs from other long-term care sectors. Results: Ten states routinely collect outcome data in ADS. Among these, 80% assess cognitive function. All 10 states capture PLWD's ability to complete activities of daily living. Presence and frequency of behavioral symptoms were collected by 80% of states. Very few or, in some cases, none of the 10 states, collected PCROs related to care planning and coordination, education, social support, and/or family caregiver burden and support. Discussion: Lack of standardized collection of PCROs hampers researchers' understanding of ADS. The vast majority of PCROs collected center on participants' physical health; conversely, data on socialization, social support, and caregiver well-being, which are purportedly the most impactful services offered by ADS centers, are rarely collected. ADS would be well served to focus on these outcome domains as the resulting data could paint a more complete picture of the holistic impact of ADS on PLWD and their caregivers.
Day centres are increasingly being established, as many older persons are isolated and in need of meaningful activities and social interaction with others. Previous research has shown that day centres are still an important arena for older attendees to socialise and engage in meaningful activities, although day centres are increasingly introducing activities as part of rehabilitation programmes to enhance physical and mental enablement. However, little is known about what attendees and staff regard as meaningful activities. Based on a multi‐site ethnographic investigation at four day centres in Denmark and Norway in 2018 and 2019, this article examines how staff and attendees alike ‘utilise’ day care centres to pursue meaningful activities and what is considered meaningful for those attending and working there. Furthermore, this article discusses the potential for person‐centred care in communities like day centres. Our study shows that activities are first and foremost perceived as meaningful if they enhance an enjoyable social dimension with ‘a touch of fresh news’. Hence, day centres function as a social space where elderly attendees can share stories and news based on personal experiences from the past and present. Consequently, person‐centred care in day care centres preferably facilitates communities to give attendees something new and refreshing to bring back home with them—and not only facilitate personal histories, preferences and wishes.
Adult day services (ADS) are one of the more popular long-term care options for racial and ethnic minority older Americans. Focusing on minority older adults, this study aims to (a) identify both the individual and structural/organizational levels factors associated with ADS use and to (b) examine ADS’ effect on health and well-being. Using the integrative review approach of Whittemore and Knafl, we found 14 studies published between 2010 to 2021. Findings concluded that individual-level needs and enabling factors were associated with ADS use and outcomes among minority older adults centered mostly on quality of life. Organizational/structural characteristics of ADS were never empirically examined in relation to service use or health outcomes. Future research should move beyond the individual level to identify and address the impact of the institutional structure, culture and practice on access, quality, and use.
The Biden-Harris Administration’s FY22 budget includes $1.6 billion for the Community Mental Health Services Block Grant program, more than double the FY21 allocation, given the rising mental health crises observed across the nation. This is timely since there have been two interrelated paradigm shifts: one giving attention to the role of the environmental context as central in mental health outcomes, the other moving upstream to earlier mental health interventions at the community level rather than only at the individual level. An opportunity to reimagine and redesign the agenda of mental health research and service delivery with marginalized communities opens the door to more community-based care interventions. This involves establishing multisector partnerships to address the social and psychological needs that can be addressed at the community level rather than the clinical level. This will require a shift in training, delivery systems, and reimbursement models. The authors describe the scientific evidence justifying these programs and elaborate on opportunities to target investments in community mental health that can reduce disparities and improve well-being for all. They select levers where there is some evidence that such approaches matter substantially, are modifiable, and advance the science and public policy practice. They conclude with specific recommendations and the logistical steps needed to support this transformational shift.
Full-text available
Horticultural therapy (HT) is used across the lifespan with individuals with a wide range of physical, social, and cognitive abilities. Older adults make up a large group of participants in horticultural activities. As the population of older adults grows, more adults face the risk of experiencing a dementing illness. Many families turn to institutional care programs, such as nursing homes and adult day service (ADS) programs, for assistance with the care of their relative with dementia. HT may be an appropriate activity to incorporate into dementia care activity programs, but formal evaluations of such programs are limited. The current study evaluated a 10-week HT program conducted with adults with dementia at an ADS program. Observations indicated that participants engaged in the horticultural activities for greater periods of time than the nonhorticultural activities. Participant affect during the horticultural and nonhorticultural activities was comparable. HT is appropriate for dementia care programs serving adults with a wide range of cognitive, physical, and social needs, and it should be considered as a viable alternative to more typical dementia care program activities.
Full-text available
Understanding the relationship between formal and informal support is becoming increasingly important for those involved in caring for the elderly (Bass et al., 1996; McAuley et al., 1990). As the elderly become more dependent on formal services and changes in demographics result in more women in the workforce and fewer available informal caregivers, there is a need for organized and efficient formal support networks that work well with, rather than replace, family helpers (Aneshensel et al., 1995; Scott & Roberto, 1985). Several models of the interface of formal-informal support have been proposed in the literature (e.g. Cantor, 1975; Edelman, 1986; Greene, 1983; Litwak, 1985). A sample of 305 primary family caregivers were interviewed at three points in time regarding their use of formal services and assistance from additional family members. It was possible to classify the sample initially into three types of family/formal interface: isolates who receive no help from family or formal services, family dependent who are assisted by kin but not formal services, and formal who receive some assistance from paid services.These groups were examined over time for stability of group membership and nursing home placement. Characteristics of caregivers and their relatives who fell in each category were also examined. There were differences in caregiver stress and rates of subsequent placement rates for people in the three initial categories of informal/formal interface (isolates, family dependent, formal), but moving from one category to another during the course of the study was more strongly associated both with care-related stress and placing the person with dementia into an institution than was stable membership in the other categories.
Full-text available
Montessori materials were used in two adult day-care cen­ ters to slow cognitive decline in adults with Alzheimer's disease. Using a within-subject design, participants in one adult day care received three months of the Montessori materials, then standard intervention later. Par­ ticipants were administered a battery of cognitive measures at baseline, three months, and six months. Favorable scores for the Montessori con­ dition were significant with the subscales ofthe Ordinal Scale of Psycho­ logical Development-Modified (total, object permanence, means-ends), Dementia Rating Scale (total, attention, concept, memory), Parachek Geriatric Behavior Rating Scale (social behavior), and the Wechsler Memory Scale (digit forward). Montessori materials appeared instru­ mental in positively influencing basic cognitive abilities of attention, ob­ ject permanence, and social behavior. (Article copies avaiLableforafeefrom The Haw011h Document Delivery Service: i-BOO-HAWORTH. E-mail address: Website: © 2002 by The Haworth Press, inc. All rights reserved.)
The Best Friends approach has been used in a Kentucky adult day center for more than 25 years. This study is a pre-post training evaluation of the Best Friends approach as used at center A when compared with a social model adult day program at center B that does not use the Best Friends approach. At each center, the participant's quality of life was measured from 3 perspectives: center staff, family member/friend, and direct observation of participant behavior. Family satisfaction with care and staff satisfaction with work were also assessed. Findings suggest that differences in ratings for the 2 programs depended on the perspective of the rater and the specific participants served. Both of these centers appeared to sustain the quality of life for their participants.
Adult day services (ADS) are an increasingly popular option for caregivers of people with dementia, but there is little research on the effects of activities on the behavior and mood of the client. This study examines participation by 94 individuals in different types of adult day-care activities and their association with changes in behavior and psychological symptoms of dementia (BPSD) for the client during a three-month span. Three domains of BPSD were examined: restless behaviors, mood behaviors, and positive behaviors. Using growth curve modeling, results show that the restless and mood behavior domains, on average, were stable over three months, whereas positive behaviors increased. For all three behavior domains there were individual differences in average level of BPSD. Average rate of change for individuals also varied from the mean for restless and mood behaviors. Physical activities, social activities, engaging activities, and watching and listening activities, along with a day-care dosage variable, were used as covariates to explain these individual differences in change. Engaging activities explained some of the individual variance for restless behaviors; as individuals increased one increment in engaging activities, they had fewer restless behavior problems over time. These results suggest that some features of programming may be related to improvements in restless behavior.
The effects of repetitive work on Alzheimer ' disease (AD) patientfunctioning were examined when nine veterans were movedfrom a work program to a traditional adult day care program. Subjects were reassessedfour months after the move with the Mini-Mental State Examination (MMSE), Cognitive Performance Test (CPT), and Geriatric Depression Scale (GDS). Individual slopes were calculatedfor seven subjects who had longitudinal scores, and expected scores were predicted based on the rate ofdecline. Observed scores at reassessment were significantly lower than expected scores. The MMSE was on average 4.9 points lower, and the CPT. 64 points lower than expected. The GDS did not change. The spouses of all nine patients reported declines in daily living activities. Compared to traditional day care activities, work activities involve sequencing skills and practice may translate to self-care activities at home.
Using an interview format, this exploratory study examined the narratives of 15 Mexican American primary caretakers and the perceived effects of adult day care centers (ADCs) on the lives of their elderly, impoverished parents. Emergent themes and categories included (a) caretaking and gender differences, (b) resistance to nursing homes, (c) negative perceptions of White caregivers, (d) perceived positive effect of ADCs on the elderly parent's physical and emotional (depression) states and the elderly parent-caregiver relationship, and (d) the negative effects of stress associated with caregiving. The data also provide insight into complicated dynamics regarding the differential treatment of daughters and sons in Mexican American families. Pearlin's stress process model provides explanations for the buffering effects of ADCs reported by caregivers.
Research supports both the role of lifestyle to promote health and well-being for older adults and preventive occupational therapy lifestyle redesign to promote engagement in life activities and enhance health for at risk community living elders. Occupational therapy lifestyle redesign programs seek to provide older adults with strategies and opportunities to increase participation in identified meaningful activities for life satisfaction and to positively impact physical and mental health. This article reports on a 16-week lifestyle redesign pilot study conducted within medical model adult day programs with cognitively intact frail older adults. Data analysis found that experimental group subjects showed favorable results on Role Functioning, Bodily Pain, and General Health on the 36-item Short Form Health Survey (SF-36); Social Activity on the Functional Status Questionnaire; and on the Center for Epidemiologic Studies Depression Scale (CES-D). No statistically significant differences were noted between groups upon posttests after adjusting for covariates; however, a small sample resulted in limited statistical power. Further studies with a larger sample are recommended for convincing conclusions. PREVENTIVE occupational therapy lifestyle design programs have been successful in promoting functional capabilities and quality of life among community living older adults. 1-3 Lifestyle changes such as the use of environmental modifications or different methods of performing everyday activities can maximize independence and improve quality of life. Chronically ill, frail older adults are at high risk for functional decline, and have reduced opportunities to participate in family and community events. This article presents the outcome of a randomized, experimental pilot program conducted within adult day programs. Group-oriented prevention programs led by occupational therapists aimed to provide the setting and opportunity for adult day program clients to problem-solve and share experiences and develop the confidence to tackle 21st century challenges. These challenges range from using a microwave oven for cooking to learning the intricacies of the Internet to e-mail grandchildren and shop on-line. This study was the first of its kind among clients attending New York State medical model adult day care programs. It is well-recognized that our population is aging and that the majority of today's older adults are enjoying their senior years because of improved health and opportunities to enjoy varied pursuits. 4,5 However, while the majority of adults 65 to 74 years old are living independently in the community, the proportion of persons 85 years and older who need assistance in activities of daily living is more than double that of persons 84 and younger. 6,7 While overall disability rates are declining for adults 65 years and older, more and more of those who are 85 and older are coping with the symptoms of chronic illness, often in combination with functional limitations. 4,8 Recent data indicates that 58% of those over 80 have a major disability. 9 Disability often results from the multiple interactions of disease processes in combination with age-related factors. 10 Disabled older adults face daily challenges in performing once simple everyday activities. 11,12 When disabilities markedly restrict functional capabilities, assistance is needed to perform personal care, to ensure safety, and to maintain community living. Older adults and their families commonly struggle to develop caregiving routines and strategies that meet care recipient and family needs. Family caregiving efforts are often supplemented by paid in-home assistance. 13-15 Older adults prefer to live in their communities and own homes, regardless of chronological age or need for assistance with activities of daily living or instrumental activities of daily living. 16,17 However, individual circumstances or necessity often encourages or requires relocation to senior housing complexes, assisted living settings, coresidence with family members or friends, or to adult foster homes. 4,18,19 As of 1997, 20.9 million households were headed by older persons, 79% of whom were homeowners. Thirty-one percent of noninstitutionalized elders lived alone as of 1998. This represents 41% of older women and 17% of older men. Only 4.3% of adults 65 years and older live in nursing homes, and among the oldest-old (85 years and older) 19% resided in nursing homes. 20 Thus, the vast majority of older adults, including persons with functional impairment and disability, live in their own homes. However, successful community living typically requires individuals to achieve some level of self-care capability, particularly for individuals who live alone. 21 For those with chronic illness, functional impairment or disability, independent mobility and self-care is achieved through perseverance and physical and emotional effort. Daily tasks that once were easy to accomplish commonly require more mental and physical effort, planning, and sometimes help from family, friends, or paid caregivers. 13-15 Families provide the first line of support for older individuals, such that the entire family unit is affected when an older adult faces illness or disability and difficulties caring for household and personal needs. This situation can happen gradually or suddenly as a result of physical or cognitive impairments. Formal care and programs optimally complement informal caregiving provided by family and friends, especially when older adults need daily supervision and assistance, or when individuals live alone and are at risk for isolation. 9,11,14,22 However, changing family dynamics and societal changes increases the need for a sharing of functions and integration of informal and formal care and supports, including use of community-based services and programs.
While adult day services (ADS) continues to grow within the home and community-based services sector, questions remain as to the challenges that the industry faces and anticipates facing in the future. In this study, a national sample of ADS centers (N = 557) responded to open-ended questions regarding current and future challenges. Qualitative and quantitative analyses revealed that funding was a central concern around which a complex and interconnected constellation of challenges revolved, such as adequate staffing, marketing their services, physical space, and complicated care needs.Given the challenging economic times, these findings suggest that the continued evolution of the ADS industry depends largely on the implementation of changes in policy and funding mechanisms.