About 900,000 people in the United States live in assisted living, and roughly 15% could transfer to nursing homes annually—but little is known about the risk factors associated with having to make that move.

To that end, researchers at the University of Michigan School of Nursing looked at data from assisted living home residents in the U.S. over eight years, to understand which residents transferred to nursing homes or stayed in assisted living, and why.

They identified their risk factors at the beginning of the study, and throughout the eight years. Their goal was twofold: to see which factors in the beginning were associated with transfer to a nursing home later; and to see which factors over time were associated with transfer to a nursing home within the study period.

Findings include:

• Fifteen percent of older adults in assisted living transferred to a nursing home over the eight years.
• Better physical performance and college education at the beginning of the study were associated with a lower risk of transfer to a nursing home.
• Maintaining better physical performance and activities of daily living and participating in physical activity over time were associated with a lower risk of transfer to a nursing home.

Jung Yoen Son, first author of the study and a Ph.D. candidate in nursing, said that education level could contribute to forming a healthy lifestyle that persists into older adulthood.

“It could affect how they manage a chronic condition, how much time and resources they’ll spend to manage a chronic condition, how much time they are going to spend participating in healthy behavior,” she said. “All of this could eventually impact any health outcome.”

Physical performance is an objective test that measures things like balance, and this impacts the level of physical activity. Activities of daily living are things like going to the bathroom, brushing teeth, eating and dressing.

One surprising finding was that at the beginning of the study, people reported that they had maintained the ability to perform activities of daily living, but had substantial problems related to mobility on physical performance tests.

Study principal investigator Janet Larson, the Shake Ketefian Collegiate Professor of Nursing, said one reason for this discrepancy is that activities of daily living are self-reported and don’t stress the system like measures of physical performance, which is an objective test.

“It’s easier to maintain your activities of daily living than it is to get really high scores on performance,” she said.

Larson said the findings may convince people in assisted living to move more, if they’re not already.

“One of my primary motivations is to look at that (risk factors) and help people understand the implications,” she said. “You’ll have some people very concerned about their physical activity and maintaining their ability to be mobile, but you’ll have other people who say, ‘I worked all my life, I’m here to rest.’ The fact is that if physical performance and physical activity decline, you are at risk for going to a nursing home, and nobody wants to go to a nursing home.”

Understanding these risk factors can also help assisted living facilities design programs to help at-risk residents, Son said.

The study, which appears in the Journal of the American Geriatrics Society, included 970 participants who were 65 or older and who resided in assisted living facilities between 2011 and 2019. Of those, 143 transferred to nursing homes.