tional Center for Health Statistics (NCHS) should help ... Data on nursing home residents are from the ... the home. Criteria usedto define dependence in the ADLs and IADLs for noninstitution- .... Belcrest Road, Hyattsville, MD 20782, or call.
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Long-tern Care for the Functionally Dependent Elderly Inhtoduction Greater attention has focused recently on financing of long-term care, due both to the growing burden to society and individuals and to the increasing size of the elderly population at risk of needing long-term care. As a result, insurance companies underwriting private long-term care insurance policies, legislators, and other policy makers need estimates of the population most at risk of needing longterm care. A recent report from the National Center for Health Statistics (NCHS) should help such policy makers plan for long-term care services.' The report was based on combined data from the Supplement on Aging (SOA) to the 1984 National Health Interview Survey (NHIS) and the 1985 National Nursing Home Survey (NNHS). In brief, the NHIS is a continuing national survey of the health of people residing in households in the United States. The SOA was added in 1984 to obtain information about older persons that had not been available previously from a national survey. All persons age 65 years and over and half of those ages 55-64 in responding NHIS households were included in the SOA sample; 97 percent of those eligible participated in the SOA (16,148 people) of whom 92 percent responded for themselves. Descriptions of the NHIS and SOA have been published.2,3 Address reprint requests to Esther Hing, Division of Health Care Statistics, National Center for Health Statistics, 6525 Belcrest Road, Room 950, Hyattsville, MD 20782.
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Data on nursing home residents are from the 1985 NNHS, a national probability sample of nursing homes, their residents, discharges, and staff. Homes included in the NNHS were nursing and related care homes in the conterniinous United States, without regard to the level of care, whether they participated in Medicare or Medicaid, or whether they were licensed. Board and care homes and residential care homes were excluded. Nursing home resident estimates are based on the sample of 4,650 residents ages 65 years and over from the 1,079 nursing homes participating in the survey. Residents included in the sample were those on the nursing home's roster as of the night before survey. Data were collected by interviewing knowledgeable nursing home staff members, who referred to the residents' medical records when necessary. The response rate for the resident sample was 97 percent.4 The report profiles long-term care use by functionally dependent people age 65 years and over, where functionally dependent is defined as receiving human assistance with at least one activity of daily living (ADL) or instrumental activity of daily living (IADL). Persons who did not perform or were unable to perform the activity were also considered dependent. ADLs are the basic personal functions of bathing, dressing, eating, getting in or out of a bed or chair, mobility, using the toilet, and continence. IADLs are everyday activities that enable an individual to live independently in the community: preparing meals, shopping, managing money, using the telephone, doing light or heavy housework, and getting around outside the home. Criteria used to define dependence in the ADLs and IADLs for noninstitutionalized people were largely based on those
used in an earlier report on the physical functioning of the aged.5
Noninstitutionalized Elderly Dependence in the ADLs for noninstitutionalized people was defined as: 1) having difficulty performing the activity because of a chronic condition and receiving help of another person in performing the activity; or 2) being unable to perform the activitywithout special equipment and not having that equipment. Dependence in the IADLs for this population was defined as having difficulty or inability to perform the activity without assistance because of a health problem.
Institutionalized Elderly On the other hand, dependence in the ADLs for nursing home residents was defined as requiring (needing) assistance of another person or special equipment to perform the activity. Dependence in the IADLs for nursing home residents was defined as receiving personal help or supervision to perform the activity. For the purposes of this report, it was assumed that the effect of differences in question wording between the SOA and the NNHS ("receiving" versus "needing" help) was minimal because residents in an institutional environment are likely to receive assistance if they need it. It was also assumed that all nursing home residents were dependent in two IADL activities (preparing meals and doing heavy housework) routinely provided in nursing homes, even though not all residents were dependent in these activities.
Results Based on combined estimates of the institutionalized and noninstitutionalized population of the United States, 29 percent of people age 65 years and over in
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one ADL or IADL, while help provided without compensation was considered informal home care. In 1984-85, 79 percent of the functionally dependent elderly population received long-term care services (Table 1). Informal home care by family and friends was the most commonly received type of long-term care (42 percent). About 21 percent received formal home care services, often in combination with informal home care. About 16 percent of the functionally dependent elderly resided in nursing homes. The percent of functionally dependent elderly persons receiving these three types of long-term care is much higher than that for the general elderly population. In 1984-85, the percent of elderly receiving informal home care was 12 percent, while 6 percent received at least some formal home care service. Only 5 percent of the elderly resided in nursing homes (Table 1). The degree of dependency in the ADLs and IADLs was associated with the type of long-term care used by functionally dependent persons. Home care use Percent~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ was greater among those with only IADL limitations or four or fewer ADL limitaPercent tions; nursing home use was greatest 80 among those dependent in five to seven ADLs. There was a nearly linear relationship between the percent of functionally dependent elderly residing in nursing 60 homes and the number of ADL dependencies. About 76 percent of the elderly dependent in all ADL functions were in nurs40 ing homes compared with 4 percent of the elderly dependent in only one ADL function (Figure 1). This finding, however, is affected by the fact that many nursing 20 homes have policies that do not permit a resident to perform the ADLs or IADLs without assistance. Because functional dependency in ADL and IADL activities is higher at 2 ADLs 3 ADLe 4 ADLs 5 ADLs 6 ADLs 7 ADLe IADL only 1 ADL older ages (from 20 percent among those Level of ADL or IADL dependency ages 65-74 years to 66 percent among FIGURE 1-Percent of functionally de det persons age 65 years and over reiding those ages 85 years and over), overall use ency: Unid Staes, In nursing homes by lee of ADL or IADL depd of long-term care, and use of nursing 1984 -85 homes in particular, was also higher at older ages. The percent of functionally de1984-85, or 8 million persons, were funcAlthough long-term care has tradipendent elderly using long-term care increased from 71 percent among those ages tionally meant nursing homes, it also intionally dependent and at risk of needing cludes the services of home health agen65-74 years to 93 percent of those ages 85 long-term care services. About threefourths of this population had only slight cies, visiting nurses, adult day care years and over; nursing home use incenters and other community-based servlimitations in these functions; 49 percent creased from 6 percent among those ages were dependent in only one or two ADLs 65-74years to 36 percent among those age ices, as well as care provided informally and 25 percent were dependent in only the by family and friends. This report exam85 years and over. The average age of ined three types of long-term care: nursing IADLs. About 9 percent were moderately functionally dependent elderly in nursing home care, formal home care, and inforhomes was 83 years, while that of their dependent, receiving assistance in three to counterparts using any fonrmnal or only infour ADLs, while 17 percent were semal home care. Formal home care services were defined as receipt of paid-for formal home care services was 78 and 77 verely dependent, receiving assistance in nearly all ADLs and LADLs. personal assistance in performing at least years, respectively. Besides age, other
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35 -
Percent
30
2520-
10
1-2 ADLs 3-4 ADLs 5-7 ADLe Level of IADL or ADL dependency FIGURE 2-Percent of furtonally dependent home care recipients receing both formal and infomal home care services: United States, 1984-85
IADL only
factors found to be significantly associated with nursing home use were being female, White race, being unmarried, and having income below the poverty threshold. Home care services (formal or informal) were used by a younger, less dependent population. Availability of an informal support network of fanmily and friends appears to be associated with receipt of informal care; among the functionally dependent elderly, use of informal home care services was greater for males, for persons hvingwith a spouse or others, and for married persons; use of any formal home care services was greater for females, for persons living alone, and for unmarried persons. The greater use of informal home care services by Black functionally dependent elderly coincides with their greater likelihood of living with spouse or others (potential caregivers). Functionally dependent elderly persons with income above the poverty threshold were more likely to use both formal and informal home care services. Use of formal home care services, however, was also dependent on the level of ADLorLADLlimitations. Formal home care services were used to augment informal care provided by family or friends
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more often among the severely dependent elderly than among those with few limitations. Thirty-two percent of home care recipients dependent in five to seven ADLs, and 27 percent of the elderly home care recipients dependent in three to fourADLs relied on both formal and informal caregivers, compared with 13 percent of home care recipients dependent in only the IADLs (Figure 2). Persons living alone were four to five times more likely to use only formal home care services than those livingwith spouse or others; persons living with spouse or others were more likely to receive only informal home care services.
Diwussion While this report presents a more complete picture of long-term care use by the functionally dependent elderly population than available by looking at only the nursing home or the community-dwelling population, the data have limitations in interpretation. First, there are reporting differences in the SOA and NNHS data; the surveys had different respondents (selfreport versus nursing home staff), and the question wording was not always identical. Second, the two surveys were fielded
in different years. This problem, however, should be negligible since the proportion of the noninstitutionalized population that was functionally dependent did not change between 1984 and 1986. Further research is possible by accessing public use data tapes for the 1984 SOA and the 1985 NNHS. The 1984 SOA can be obtained from the Division of Health Interview Statistics, National Center for Health Statistics in Hyattsville, Maryland. The 1985 NNHS can be obtained from the National Technical Information Service in Springfield, Virginia. Both data tapes are also available from the National Archive of Computerized Data on Aging (NACDA) from the Inter-university Consortium for Political and Social Research at the University of Michigan in Ann Arbor, Michigan. E Esther Hing, BS Barbar Bk,om, WPA Copies of the report, Loqg-tenn Care for the Functionally Dependent Elderly, by Hing and Bloom, Vatal Health Stat 13 (104) can be purchased from the US Government Printing Office, Washington, DC 20402. Order stock no. 017-022-01116-6. The price is $3.00. For more information about this and other reports and data from the National Center for Health Statistics, write to the Scientific and Technical Information Branch, NCHS, 6525 Belcrest Road, Hyattsville, MD 20782, or call (301) 436-8500.
References 1. Hing E, Bloom B: Long-term care for the functionally dependent elderly. National Center for Health Statistics. Vital Health Stat 13(104). Washington, DC: Public Health Service, 1990. 2. Kovar MG, Poe G: The National Health Interview Survey Design and Procedures. National Center for Health Statistics. Vital Health Stat 1(18). Washington, DC: Public Health Service, 1989. 3. Fitti J, Kovar MG: The Supplement on Aging to the 1984 National Health Interview Survey. National Center for Health Statistics. Vital Health Stat 1(21). Washington, DC: Public Health Service, 1987. 4. Hing E, Sekscenski E, Strahan G: The National Nursing Home Survey: 1985 Summary for the United States. National Center for Health Statistics. Vital Health Stat 13(97). Washington, DC: Public Health Service, 1989. 5. Fulton JP, Jack SS, Katz S, Hendershot G: Physical functioning of the aged: United States, 1984. National Centerfor Health Statistics. Vital Health Stat 10(167). Washington, DC: Public Health Service, 1989.
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