Resarch Findings #5: Characteristics of Nursing Home Residents--1996

Nancy A. Krauss, M.S., and Barbara M. Altman, Ph.D. Agency for Health Care Policy and Research

Introduction

Although people residing in nursing homes represent a small proportion of both the elderly population and the general population with disabilities, they are an important part of the long-term health care system. Nursing homes primarily exist to serve members of these populations who have severe medical and disability problems that require nursing home care. A lack of financial resources or family caregivers also contributes to the need for these institutions (Congressional Budget Office, 1991).

This report, based on the 1996 Nursing Home Component (NHC) of the Medical Expenditure Panel Survey (MEPS) from the Agency for Health Care Policy and Research, presents a profile of the residents of nursing homes in the United States on January 1, 1996. Nursing homes which are part of larger facilities that also provide independent living and/or personal care units are included in the sample. However, this report describes only nursing home residents, not persons who are residents in personal care homes, assisted living facilities, or other types of facilities that provide long-term care.

The age distribution, race, marital status, and other sociodemographic characteristics of nursing home residents, along with the physical and functional characteristics associated with their need for nursing care, are described. The nationally representative estimates reported here are based only on a sample of current residents. (Current residents are sampled residents living in the sampled nursing home on January 1, 1996, the beginning of the data collection reference period.) Although data for the whole year were subsequently collected for these residents, along with data on a second sample of new admissions in 1996, the estimates in this report represent current residents in nursing homes as of January 1, 1996. The technical appendix presents details concerning sample selection, data collection, questionnaire items, data editing, and statistical procedures for deriving estimates. Definitions of terms used in this report are also included.

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Demographic Characteristics

In 1996, there were approximately 1.56 million nursing home residents in the United States (Table 1). The majority were in private for-profit facilities (65.8 percent). Another quarter (24.5 percent) were in private nonprofit facilities, and the remaining 9.7 percent resided in government-owned and operated facilities. (Government facilities include city, county, State, Department of Veterans Affairs, and other Federal facilities.) Most residents (81.0 percent) lived in facilities that contained only nursing home beds. However, 12.3 percent resided in facilities that also had independent living or personal care beds, such as continuing care retirement communities (CCRCs).

An examination of the demographic characteristics of nursing home residents revealed the following:

• Women composed more than two-thirds (71.6 percent) of the total nursing home population and outnumbered men in all facility types. However, women represented a lower proportion of residents in government facilities (53.5 percent) than in for-profit (72.4 percent) and nonprofit (76.7 percent) facilities.
• Approximately half of all current residents (49.3 percent) were age 85 and over. Nonprofit nursing homes had a larger proportion of persons age 85 and over (58.9 percent) than either for-profit (48.0 percent) or government facilities (34.2 percent). Nursing homes with independent living or personal care beds had larger proportions of residents age 85 and over (58.7 percent) than did hospital-based nursing homes (40.9 percent) or nursing homes with only nursing home beds (48.6 percent).
• Less than a tenth (8.8 percent) of current nursing home residents were under age 65. A larger proportion of residents in government facilities (14.8 percent) than in for-profit (9.1 percent) or nonprofit (5.7 percent) facilities were under age 65. Hospital-based facilities had a larger proportion of residents under age 65 (14.4 percent) than did facilities with independent living or personal care beds (5.5 percent) or facilities with only nursing home beds (8.9 percent).
• The majority (88.7 percent) of nursing home residents were white, 8.9 percent were black, and the remainder were of other races. Facilities with independent living or personal care beds had a smaller proportion of black residents (4.1 percent) than either hospital-based facilities or nursing homes with only nursing home beds (10.4 percent and 9.4 percent, respectively).
• Only 16.6 percent of residents were married. The remaining residents were widowed (59.8 percent), divorced or separated (9.2 percent), or never married (14.4 percent).
• The smallest percentage of the nursing home population was found in the West (15.3 percent). In both the South and Midwest, the nursing home population was approximately twice the size of that in the West (490,900 and 485,100, respectively, compared with 238,800).
• The largest proportion of residents in for-profit facilities was in the South. Residents in facilities with independent living or personal care beds were most likely to be in the Midwest and least likely to be in the West.
• Overall, two-thirds of the nursing home population were in nursing homes in metropolitan areas (69.1 percent). However, the population in hospital-based facilities was more evenly distributed, with three-fifths (57.8 percent) in metropolitan areas and two-fifths (42.2 percent) in nonmetropolitan areas.

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Insurance Enrollment

The insurance data found in Table 1 indicate the insurance programs in which residents were enrolled but do not reflect the insurance source paying for nursing home care. (Additional nursing home data, including data on source of payment, are made available in the MEPS section of the AHRQ Web site—http://www.ahrq.gov—on an ongoing basis.) Most nursing home residents (93.2 percent) were enrolled in Medicare, and approximately two-thirds (67.9 percent) were enrolled in Medicaid. More than half of residents in all types of facilities were enrolled in both Medicare and Medicaid. Only 2.4 percent were enrolled in neither of these public insurance programs. Persons in hospital-based facilities were less likely than residents in other types of facilities to be enrolled in a public insurance program.

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Level of Dependence

More than four-fifths (83.3 percent) of nursing home residents received help with three or more activities of daily living (ADLs), including bathing, dressing, toileting, transferring from a bed or chair, feeding, and mobility (Table 1). However, a small proportion (2.8 percent) did not receive assistance with any of these activities. Residents of hospital-based facilities were less likely to receive assistance with ADLs than residents in facilities with nursing home beds only. When nursing home residents did receive assistance, bathing and dressing were the most common tasks with which they received help (96.5 percent and 88.2 percent, respectively, as shown in Table 2).

Data presented in Table 2 describe the various levels of assistance received by men and women of various ages. Findings include the following:

• Residents under age 75 were more likely than older residents to have no ADL limitations and were less likely to have three or more ADL limitations. Only 1.9 percent of residents ages 75-84 and 1.7 percent of residents age 85 and over were without ADL limitations.
• Women were more likely than men to have problems with mobility around the facility. Women also were more likely than men to be totally dependent when transferring (29.6 percent compared with 25.4 percent) and dressing (37.1 percent compared with 33.1 percent).
• Women nursing home residents were more likely than men to receive help with three or more ADLs (84.7 percent and 79.6 percent, respectively).
• Two-thirds of residents had problems with mobility such that they received assistance getting around the facility (36.5 percent) or were totally dependent on others for movement within the facility (30.0 percent).
• Residents under age 65 were as likely as residents age 75 and over to be totally dependent in bathing, dressing, and mobility and more likely to be totally dependent in eating and transferring.

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Other Functional Characteristics

A number of factors may contribute to the decision to place a patient in a nursing home. These are described in some detail in the following paragraphs.

Toileting and Incontinence

Research has shown that once incontinence occurs in an elderly person who already displays other limitations, it is often difficult to maintain that person in the home setting (Coward, Horne, and Peek, 1995). Table 2 indicates that 79.7 percent of nursing home residents required assistance with toileting needs. Assistance includes, but is not limited to, help with transferring on and off the toilet, reminders to use the bathroom, or help with bathroom hygiene. The residents who were most dependent were those who could not control their bowel or bladder functions at all. As shown in Table 3, more than half of nursing home residents (54.0 percent) were incontinent. This includes those who were bowel incontinent only (5.1 percent), bladder incontinent only (11.3 percent), and both bowel and bladder incontinent (37.6 percent).

Memory and Orientation Problems

Memory loss is another important reason that individuals are placed in nursing homes. Forgetfulness and disorientation can be dangerous problems that require 24-hour supervision to provide for the individual's safety and well-being. Nearly three-quarters (70.8 percent) of nursing home residents had some form of loss in either short-term memory, long-term memory, or both (Table 4). About the same proportion had problems with orientation, such as knowing where they were, what season of the year it was, or the identity of staff members. Specific demographic characteristics associated with these problems include the following:

• Persons over age 75 were significantly more likely than younger nursing home residents to exhibit problems with memory loss: 47.0 percent of residents under age 65 and 39.9 percent ages 65-74 had no problems with memory loss, compared with only 29.1 percent of residents ages 75-84 and 23.6 percent of those age 85 and over.
• Nursing home residents under age 65 were less likely than persons age 75 and over to have both short- and long-term memory loss (41.6 percent, compared with 53.4 percent for persons 75-84 and 56.9 percent for persons 85 and over). However, they were more likely than persons age 75 and over to have problems with orientation in three or more areas (62.8 percent, compared with 50.9 percent for persons 75-84 and 44.9 percent for persons 85 and over).
• Men were less likely than women to have any memory loss (33.5 percent compared with 27.5 percent), but they were more likely than women to have a problem with orientation in three or more areas (54.3 percent compared with 48.2 percent).

In addition to problems with memory loss and orientation to their surroundings, many nursing home residents (80.6 percent) exhibited problems making daily decisions. While there were no significant gender differences in daily decision making, persons ages 65-74 were less likely to be severely impaired than persons age 75 and over.

Behavior Problems

Behavior problems existed among nursing home residents, but they were not as common as the cognitive problems discussed above (Table 4). Almost a third (30.2 percent) of nursing home residents exhibited at least one form of inappropriate or dangerous behavior— verbally or physically abusive behavior, socially inappropriate behavior, wandering, or resistance to care. Overall, there were no significant differences among age groups in behavior problems, but male residents were more likely than female residents to have a behavior problem (34.9 percent compared with 28.4 percent).

The most frequently occurring behavior problem was socially inappropriate behavior, such as making disruptive sounds, inappropriate sexual behavior or disrobing in public, smearing or throwing food or feces, and hoarding. Some form of socially inappropriate behavior was exhibited by 14.5 percent of the nursing home population. In comparison, 12.5 percent of residents exhibited resistance to care, 11.8 percent were verbally abusive, and 9.1 percent were physically abusive.

As shown in Table 4, there were negligible differences by age and gender in the overall occurrence of behavior problems. However, specific problems were associated more with one age or gender than another, including the following:

• Men were somewhat more likely than women to exhibit both verbally abusive behavior (14.3 percent compared with10.8 percent) and physically abusive behavior (11.5 percent compared with 8.2 percent). Men also were more likely than women to resist care (14.6 percent compared with 11.7 percent).
• A fifth (20.8 percent) of residents under age 65 exhibited socially inappropriate behavior, compared with approximately 14 percent of older residents (13.9 percent for ages 65-74, 13.6 percent for ages 75-84, and 14.0 percent for age 85 and over).

Health Conditions

Health conditions are active diagnoses that have a relationship to current ADL status, cognitive status, mood and behavior status, medical treatments, nurse monitoring, or risk of death. The most frequently occurring conditions among nursing home residents were dementias, various forms of heart disease, hypertension, arthritis, and cerebrovascular accidents. The data shown in Table 5 are based on the health conditions recorded in the Minimum Data Set (MDS), a mandated record system required for all federally certified nursing homes regardless of the resident's payer.1 Other frequently occurring conditions among this population were depression, diabetes, anemia, allergies, and chronic obstructive pulmonary disease.

1 hese preliminary estimates are based on the initial Round 1 data from only the MDS collected during the first 3 to 4 months of the survey year. They are subject to adjustment when all condition data for the full year are collected, coded, and edited.

Although these conditions were the 10 most prevalent conditions recorded in the MDS among all residents of nursing homes on January 1, 1996, the prevalence of these conditions varied by age and gender. Figure 1 shows that persons under age 65 were significantly less likely to have dementia (17.7 percent), heart disease (16.6 percent), hypertension (25.3 percent), and arthritis (4.5 percent) than were persons 65 and over.

Younger nursing home residents also were more heterogeneous than those 65 and over with regard to health conditions. The overwhelming majority (90.2 percent) of residents age 65 and over had at least one of the five most prevalent conditions for that age group, while only 64.8 percent of persons under age 65 had one or more of the five most prevalent conditions observed in that age group (Figure 2).

Gender differences in the prevalence of disease among nursing home residents were also evident (Table 5). Women were more likely than men to have dementia (48.9 percent compared with 44.6 percent), hypertension (38.4 percent compared with 32.0 percent), and arthritis (26.9 percent compared with 17.5 percent). Women and men were equally likely to have some form of heart disease, but women were less likely than men to have had a cerebrovascular accident (19.2 percent compared with 26.3 percent) or to have chronic obstructive pulmonary disease (10.6 percent compared with 17.9 percent).

Other health conditions correlated with age include the following:

• Close to half of all nursing home residents (47.7 percent) had some form of dementia; more than half of those age 85 and over had dementia (53.6 percent).
• Problems with heart disease increased as the age of the nursing home population increased, steadily rising from 16.6 percent of residents under age 65 to 55.6 percent of residents age 85 and over. There were no significant differences between male and female residents.

Sensory and Communication Problems

More than a tenth (12.6 percent) of the nursing home population had highly impaired hearing and more than a tenth (13.4 percent) had highly impaired sight (Table 5). Persons age 85 and over were much more likely than younger nursing home residents to have high levels of hearing impairment. The prevalence of impaired sight varied less by age. There were no significant differences between men and women in the proportion with high levels of hearing or sight impairment.

Communication—understanding and being understood—was a more common problem for nursing home residents. More than half (60.1 percent) had some communication problem, and 44.3 percent had difficulty with both being understood and understanding others. Generally, the effects of age or gender on communication problems were modest, although nursing home residents under age 65 were less likely than those age 85 and over to have problems both understanding and being understood or problems only in understanding.

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Conclusions

In 1996, nursing home residents were highly dependent on assistance in performing ADLs. Most exhibited memory loss, or orientation or decision making problems that could make independent living dangerous. Behavior problems were present in a smaller proportion of residents than cognitive problems. However, communication problems occurred in more than half of the population and could be an impediment to proper care.

The types of medical conditions experienced by residents varied by gender and age. Overall, nursing home residents under age 65 had fewer of the most frequently occurring conditions than older residents, but the younger residents were either as dependent or more dependent on assistance with ADLs. They were less likely to have both short- and long-term memory problems than residents over age 65. Residents under age 65 also were more likely than residents age 75 and over to have severe problems with decision making and orientation. Current nursing home residents, regardless of age or gender, have serious problems with ADLs, continence, and behavior.

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Tables

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Figures

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References

Agency for Health Care Policy and Research. Round 1, facility-level public use file codebook. In: Medical Expenditure Panel Survey (MEPS) NHC-001: Round 1 Sampled Facility and Person Characteristics, March 1997 [CD-ROM]. Rockville (MD), 1997. AHRQ Pub. No. 97-DP21.

American Hospital Association. American Hospital Association guide to the health care field, 1996-97 edition. Chicago (IL); 1996.

Bethel J, Broene P, Sommers JP. Sample design of the 1996 Medical Expenditure Panel Survey Nursing Home Component. Rockville (MD): Agency for Health Care Policy and Research; 1998. MEPS Methodology Report No. 4. AHRQ Pub. No. 98-0042.

Congressional Budget Office (US). Policy choices for long-term care. Washington; 1991.

Coward RT, Horne C, Peek CW. Predicting nursing home admissions among incontinent older adults: a comparison of residential differences across six years. The Gerontologist 1995;35(6):732-43.

Potter DEB. Design and methods of the 1996 Medical Expenditure Panel Survey Nursing Home Component. Rockville (MD): Agency for Health Care Policy and Research; 1998. MEPS Methodology Report No. 3. AHRQ Pub. No. 98-0041.

Shah BV, Barnwell BG, Bieler GS. SUDAAN user's manual: software for the statistical analysis of correlated data. Research Triangle Park (NC): Research Triangle Institute; 1995. U.S. Bureau of the Census. Statistical abstract of the United States: 1996 (116th edition). Washington; 1996.

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Appendix

Data Sources and Methods of Estimation

The data in this report were obtained from a nationally representative sample of nursing homes from the Nursing Home Component (NHC) of the 1996 Medical Expenditure Panel Survey (MEPS). The sampling frame was derived from the updated 1991 National Health Provider Inventory. The NHC was primarily designed to provide unbiased national and regional estimates for the population in nursing homes, as well as estimates of these facilities and a range of their characteristics.

The sample was selected using a two-stage stratified probability design, with facility selection in the first stage. The second stage of selection consisted of a sample of residents as of January 1, 1996, and a rolling sample of persons admitted during the year (Bethel, Broene, and Sommers, 1998). Of the 1,123 eligible nursing homes sampled in the NHC, 85 percent responded. Estimates in this report are based on these 952 eligible responding facilities. To bring the sample size in line with the original design of approximately 800 facilities by the end of Round 3, the facility sample was subsampled at the end of Round 1. A total of 127 facilities were randomly deselected.

The MEPS NHC data analyzed here were collected in person during the first of three rounds of data collection. A computer-assisted personal interview (CAPI) system was used for data collection. The Round 1 interview took place during the period March-June 1996. The entire three-round data collection effort took place over a 1-1/2 year period, with the reference period being January 1, 1996, to December 31, 1996 (Potter, 1998).

The facility questionnaire was designed to elicit information on the complex structure of institutions that provide residential care or treatment. Some nursing homes or units exist within larger establishments. In such cases, the entity that appeared on the sampling frame might be the larger facility, the nursing home or unit within the larger facility, or only one of several nursing units within the larger facility. Therefore, the NHC's Round 1 facility questionnaire was designed to identify the larger facility, each eligible nursing home or unit within the larger establishment, and other nonhospital residential parts. Because of this, the point of reference for a specific question may be the sampled nursing home or unit (hereafter referred to as "nursing home"), a larger facility, another nonhospital residential part of a larger facility, one or several nursing homes within a larger facility, or a smaller subunit of the eligible nursing home (Agency for Health Care Policy and Research, 1997).

Data on the sampled nursing homes were obtained using a facility questionnaire administered through CAPI to facility administrators or designated staff. Estimates provided are preliminary and are subject to revision as more information from other parts of the NHC becomes available.

Data in data files released to the public have, in some instances, been masked to preserve the confidentiality of responding nursing homes. As a result, estimates made using the public use version of the data may differ slightly from the estimates presented in this report.

Facility Eligibility

Only nursing homes were eligible for inclusion in the MEPS NHC. To be included as a nursing home, a facility must have at least three beds and meet one of the following criteria:

• It must have a facility or distinct portion of a facility certified as a Medicare skilled nursing facility (SNF).
• It must have a facility or distinct portion of a facility certified as a Medicaid nursing facility (NF).
• It must have a facility or distinct portion of a facility that is licensed as a nursing home by the State health department or by some other State or Federal agency and that provides onsite supervision by a registered nurse or licensed practical nurse 24 hours a day, 7 days a week (Bethel, Broene, and Sommers, 1998).

By this definition, all SNF- or NF-certified units of licensed hospitals are eligible for the sample, as are all Department of Veterans Affairs (VA) long-term care nursing units. In such cases, and in the case of retirement communities with nursing facilities, only the long-term care nursing units(s) of the facility were eligible for inclusion in the sample. If a facility also contained a long-term care unit that provided assistance only with activities of daily living (e.g., a personal care unit) or provided nursing care at a level below that required to be classified as a nursing facility, that unit was excluded from the sample (Potter, 1998).

Current-Residents Sample

To allow a chance of selection for all persons in this universe, two samples of persons were selected within each cooperating sampled facility: (1) a cross-sectional sample of persons who were residents on January 1, 1996 (referred to as current residents) and (2) a sample of persons admitted to the nursing home at any time during 1996, with no prior admissions to an eligible nursing home during 1996 (referred to as first admissions). This report is limited to data collected during Round 1, so estimates are for current residents only. For details on first-admissions sampling, refer to Bethel, Broene, and Sommers (1998).

The interviewer in each sampled facility compiled a list of current residents as of January 1, 1996. Within each facility, a systematic random sample of four current residents was drawn using the CAPI system.

The overall response rate for the current-residents sample was 84 percent (.85 facility response rate X .99 current response rate). To be considered a respondent, the sampled resident had to have 75 percent of the baseline health status items complete, and age, sex, and race had to be reported. Forty-four eligible current residents did not meet this requirement, and 17 sampled persons were ineligible.

Definitions of Variables

Nursing Home Residents

Nursing home residents included only persons residing in licensed parts of sampled nursing homes. Residents of unlicensed parts of sampled facilities were excluded.

Ownership

Respondents reported the ownership type that best described their facility (or larger part of the facility, in situations where the sampled nursing home was part of a larger facility), as follows:

• For-profit (i.e., individual, partnership, or corporation).
• Private nonprofit (e.g., religious group, nonprofit corporation).
• One of four types of public ownership—city/county government, State government, VA, or other Federal agency.

Respondents also reported whether their facility was part of a chain or group of nursing facilities operating under common management. Three facilities whose ownership type originally was reported as "other specify" were recoded based on the 1996 American Hospital Association Guide to Hospitals (American Hospital Association, 1996).

Facility Type

This variable, constructed from data from the facility questionnaire, defines the facility's organizational structure as one of three types:

• Hospital-based nursing home. This indicates that the sampled nursing home was part of a hospital or was a hospital-based Medicare SNF.
• Nursing home with independent living or personal care unit. This category includes continuing care retirement communities (CCRCs) and retirement centers that have independent living and/or personal care units, as well as nursing homes that contain personal care units. Non-hospital-based nursing homes with a separate unit in which personal care assistance is provided also are included.
• Nursing home with only nursing home beds. This category includes a small number of nursing homes (less than 1 percent) with an intermediate care unit for the mentally retarded (ICF-MR).

The order of priority for coding facility type followed the sequence listed above. Eleven facilities initially classified as "other nursing hometype" were recoded to the latter two categories on further review.

Census Region

Sampled nursing homes or units were classified in one of four regions—Northeast, Midwest, South, and West—based on their geographic location according to the MEPS NHC sampling frame. These regions are defined by the U.S. Bureau of the Census.

Facility Location

A metropolitan statistical area (MSA) was defined as including (1) at least one city with 50,000 or more inhabitants or (2) a Census Bureau-defined urbanized area of at least 50,000 inhabitants and a total metropolitan population of at least 100,000 (75,000 in New England) (U.S. Bureau of the Census, 1996).

Insurance Enrollment

Main insurance enrollment was aggregated into four mutually exclusive groups: Medicare only, Medicaid only, both Medicare and edicaid, and neither Medicare nor Medicaid. Persons covered by Medicare, Medicaid, or both may also have had other insurance coverage, such as private insurance or veterans benefits. Persons with neither Medicare nor Medicaid coverage included 1.3 percent of sampled persons with private coverage only, .7 percent of sampled persons with veterans benefits (some of whom also had private insurance), and .4 percent of sampled persons for whom no insurance coverage was identified. These data reflect insurance coverage only. The actual source of payment for nursing home stays will not be available until the release of full-year nursing home data for 1996.

Activities of Daily Living (ADLs)

Respondents were asked to indicate whether the sampled resident received assistance with personal care activities commonly known as activities of daily living. Six activities were included in the summary ADL measure in Table 1: dressing, bathing, eating, transferring from a bed or chair, mobility, and toileting. Of those sampled, 32 persons (less than 1 percent of the total) were comatose and initially had all ADLs classified as "inapplicable." These cases, along with all cases for whom it was indicated that the "activity did not occur" (less than 2 percent of the total), were reclassified as "totally dependent." Persons with missing data (not more than .5 percent of the total sample of any ADL) were assumed to have no difficulty with activities and were reclassified as "no assistance received." For Table 2, persons functioning independently were classified as "no assistance received" and persons who required supervision or limited or extensive assistance were classified as "assistance received."

Marital Status

Facility respondents were asked if, on January 1, 1996, the sampled person was married, widowed, divorced, separated, or never married.

Race

Respondents were asked if the race of each resident was best described as American Indian, Alaska Native, Asian or Pacific Islander, black, white, or other. Estimates of race were collapsed into three categories: white, black, and other. Less than .5 percent of residents initially classified as "other" were reclassified as white. The other race categories are not shown separately due to small sample size.

Memory Problems

Respondents were asked two questions about the sample resident's memory: whether the resident had a short-term memory problem and whether the resident had a long-term memory problem. Responses were limited to "yes" or "no." Approximately 1.2 percent missing data (not included in Table 4) existed for each item.

Orientation Difficulties

To assess orientation to time, place, and person, respondents were asked whether the sample resident was able to recall the current season, location of own room, staff names/faces, or that he or she was in a nursing home. The summary variable in Table 4 indicates the number of items with which the resident had difficulty. Missing data, which were not included in the table, did not exceed 1.2 percent forany item.

Ability to Make Daily Decisions

Respondents reported the sample resident's ability to make daily decisions. Residents reported to be independent were classified as "no impairment"; those with modified independence and moderately impaired were classified as "some impairment"; and those who were severely impaired was classified as "severe impairment." Missing data (less than 1.2 percent) were not included in Table 4.

Behavior Problems

Respondents were asked how often the sample resident exhibited the following problems: verbally abusive behavior, physically abusive behavior, wandering, resistance to care, or disruptive behavior. The summary variable indicates the presence of one or more of these behaviors. No individual behavior problem had more than 1.8 percent missing data. Missing data were not included in Table 4. For both the summary measures and measures of individual behavior problems, responses indicating that the resident had a problem "less than daily" and "daily or more frequently" were both classified as having a behavior problem.

Communication

Respondents reported how well the sample resident was able to understand others and whether he or she could be understood by others. Positive responses for "understood" and "usually understood" were classified as no problem; "sometimes understood" and "rarely/never understood" were classified as having a problem. Understanding others was classified in a similar manner. Responses for both variables were collapsed into four mutually exclusive categories: no problem, problem being understood, problem understanding others, or both. Missing data (less than 1 percent across both variables) were not included in Table 5.

Health Conditions

Conditions are active diagnoses that have a relationship to current ADL status, cognitive status, mood and behavior status, medical treatments, nurse monitoring, or risk of death. The health conditions listed in Table 5 were collected from the sample resident's Minimum Data Set (MDS). The MDS is a uniform series of questions assessing the nursing home resident's physical and mental status and is required by law for anyone entering a federally assisted nursing home. If a valid MDS was not available, conditions were collected from the resident's medical record. Condition estimates are preliminary and will change when full-year data are edited. Data in this report do not include conditions listed as "other specify," nor do they include conditions identified from other medical records if the resident had a valid MDS. However, these data will be included in the full-year file.

Hearing and Vision

Respondents reported sample residents' ability to hear and see using four categories ranging from adequate to severely impaired. "Minimal difficulty" was classified as "impaired," and "highly" and "severely" impaired were combined and classified as "highly impaired." Missing data (less than 2 percent for both items) were not included in Table 5.

Incontinence

Data on bladder and bowel control were collected from the MDS and refer to continence in the last 14 days. Residents were classified as incontinent if the response indicated that they were incontinent or frequently incontinent. Residents reported to be continent, usually continent, or occasionally incontinent were classified as having no incontinence. Responses for bladder and bowel control were collapsed into four mutually exclusive categories: no incontinence, bladder incontinence only, bowel incontinence only, and both bladder and bowel incontinence. Of the sample, 32 persons (less than 1 percent of the total) were comatose and initially classified as "inapplicable." These cases were reclassified as incontinent. Persons with missing data ("don't know") were assumed to have no difficulty with bowel and/or bladder control and were reclassified as continent; these persons represented less than .5 percent of the total sample for any item.

Reliability and Standard Error Estimates

Since the statistics presented in this report are based on a sample, they may differ somewhat from the figures that would have been obtained if a complete census had been taken. This potential difference between sample results and a complete count is the sampling error of the estimate.

The chance that an estimate from the sample would differ from the value for a complete census by less than one standard error is about 68 out of 100.

The chance that the difference between the sample estimate and a complete census would be less than twice the standard error is about 95 out of 100.

Tests of statistical significance were used to determine whether differences between estimates exist at specified levels of confidence or whether they simply occurred by chance. Differences were tested using Z-scores having asymptotic normal properties, based on the rounded figures at the .05 level of significance.

Estimates for sample sizes of less than 50 do not meet standards of reliability or precision and are not reported. In addition, estimates with a relative standard error greater than 30 percent are marked with an asterisk. Such estimates cannot be assumed to be reliable.

Rounding

Estimates presented in the tables have been rounded to the nearest .1 percent. Population estimates have been rounded to the nearest hundred. The rounded estimates, including those underlying the standard errors, will not always add to 100 percent or the full total.

Standard Errors

The standard errors in this report are based on estimates of standard errors derived using the Taylor series linearization method to account for the complex survey design. The standard error estimates were computed using SUDAAN (Shah, Barnwell, and Bieler, 1995). The direct estimates of the standard errors for the estimates in Tables 1-5 in the text are provided in Tables A-E, respectively.

For example, the estimate for male nursing home residents of 28.4 percent (Table 1) has an estimated standard error of .8 percent (Table A). The estimate for white nursing home residents of 1,387,000 (Table 1) has an estimated standard error of 15,089 residents (Table A).

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