Residential Settings of Adults with Difficulty in Activities of Daily Living by State: 2008-2010
Variations in state long term care policies and financing, as well as cultural and other factors, impact the residential choices of persons at risk of needing long term services and supports. There is considerable interest in the residential settings of adults who have difficulty with activities of daily living (IADL and ADL) and the fraction that reside in households versus institutional and non-institutional group settings. Beginning in 2006, the US Census Bureau's American Community Survey (ACS) provides information on adults in the United States having difficulty with IADL or ADL and the percentage living in households, institutions, and other noninstitutional group settings by state. This analysis updates estimates from the ACS that were previously provided by state using 2006-2007 data. Since the definition of disability changed in 2008, the current estimates are not comparable to earlier estimates.
Data Sources and Methods:
For each state, the percent of the total population with IADL or ADL difficulties that live in households, non-institutional group settings, or institutional group settings is reported separately for working age (25-64 years) and older adults (65 years and over). The data source is the ACS public use microdata sample (PUMS) files. Although the ACS is the nation's largest survey, the number of persons living in noninstitutional group settings is small and highly variable statistically. For that reason, three-year average estimates for the years 2008-2010 are presented.
The focus is on the total population in a state having difficulty with IADL or ADL. Individuals aged 18-24 are excluded to avoid including students living in dormitories because it is not possible in the ACS PUMS to separate dormitories from other group settings. It is also not possible to separate prisons from other institutions in the PUMS data. However, there are reasons to include the prison population: younger adults with disabilities who have difficulty with IADL and ADL can be imprisoned, especially adults with mental illness. Also, some individuals serving prison sentences may develop a disability while in prison. The prison population has more of an influence on younger adult population than for persons ages 65 and older since few reside in prisons. We include difficulty in IADL as well as ADL since both provide comparable measurement by age—when defined by the need for personal assistance—and have greater content validity for persons living in households than ADLs alone — see LaPlante, M. P. (2010). The Classic Measure of Disability in Activities of Daily Living Is Biased by Age but an Expanded IADL/ADL Measure Is Not. J Gerontol B Psychol Sci Soc Sci, (published ahead of print January 25, 2010, doi:10.1093/geronb/gbp129).
For the percentages of persons with IADL or ADL difficulties living in various residential settings, standard errors were calculated using replicate weights by the method of successive differences. For each percentage, a 95% confidence interval can be constructed by adding and subtracting the margin of error (M.E.; calculated as 1.96 x the standard error) from the estimate. Theoretically, it means that if the survey were to be repeated many times, the estimate would lie in that interval 95% of the time. Estimates for small states have less statistical reliability. Following standard statistical presentation methods, estimates with a standard error exceeding 30% of the estimate's value are flagged with an "*".
Estimates are provided of the number of persons living in the state and the number of persons who have difficulty doing errands alone such as visiting a doctor’s office or shopping (IADL disability) or have difficulty dressing or bathing (ADL disability). Estimates are also provided for the number of such persons living in institutions or non-institutional group settings and the percent of all persons with IADL or ADL difficulties by type of residential setting.
Findings for Persons Ages 65 and Older:
The states with the highest proportions of persons ages 65 and older with IADL or ADL difficulties living in institutional or non-institutional group settings are North Dakota (33.7%), Iowa (31.5%), Nebraska (28.6%), South Dakota (27.6%), and Minnesota (27.6%). These top five states are all in the West North Central Census division.
The lowest states are Nevada (8.4%), Arizona (9.0%), Utah (10.8%), Florida (12.0%), and New Mexico (12.1%). The rate of persons with IADL or ADL limitations living in group settings varies 4-fold between North Dakota and Nevada. Most of the variation is in the rate of institutionalization; the rate of noninstitutional group residence is very low in comparison. Nationally, 17.4 percent of older persons with IADL or ADL difficulties live in group settings, with 15.1 percent living in institutions and 2.3 percent in noninstitutional group settings. There is no statistically significant correlation between the rate of IADL/ADL difficulty and the rate of living in group quarters.
Findings for Persons Ages 25-64:
For adults ages 25-64, 8.8 percent of persons with IADL or ADL difficulties live in group settings, with 4.8 percent in institutions and 4.0 percent in non-institutional group settings. For working age adults, the institutional rate is a third that of older adults, while the rate of non-institutional group settings is twice that of older adults. That might reflect the higher prevalence of intellectual and developmental disabilities among working age adults and the trend towards their residing in smaller group homes instead of institutions.
The states with the highest rates of working age persons with IADL or ADL difficulties living in group settings are South Dakota (17.8%), North Dakota (17.3%), Minnesota (15.2%), Virginia (15.0%) and new York (13.5%). The lowest states are Vermont (3.0%), West Virginia (3.6%), New Hampshire (4.0%), Nevada (4.6%), and Kentucky (4.8%). South Dakota has a rate 5.9 times that of Vermont. South Dakota, North Dakota, and Minnesota have the highest rates of individuals with IADL or ADL difficulties living in non-institutional group quarters, each around 12 percent. This may reflect the de-institutionalization of persons with developmental disabilities to smaller group homes.
For ages 25-64, there is a statistically significant negative correlation between the rate of IADL/ADL difficulty and the rate of living in group quarters (r=-0.53, p<.001). Although state rates of difficulty in IADL or ADL of the total state population are highly correlated between younger and older adults (r=0.74), rates of group living arrangements are correlated only moderately highly (r=0.44) between younger and older adults. This indicates that states vary considerably in the distribution of persons with IADL and ADL difficulties by residential setting by age.
The rate of persons living in institutional and non-institutional group settings has been calculated for the LTSS population at risk, that is, persons who have difficulty with IADL or ADL. The results are consistent with prior studies of nursing home use. In particular, it is known from the National Nursing Home Survey that the Midwest region has twice the rate of nursing home residents per capita than the Western region. This analysis confirms that finding among persons ages 65 and older, but reveals further that some Midwest states also have higher rates of non-institutional group settings among persons ages 25-64. The variation across states in the percent of older persons with IADL or ADL difficulties residing in group settings is large, with the highest states having 4 times the rate of the lowest states. These variations in the rate of living in group settings need to be better understood, and likely reflect differences in demographics, cultural norms, policies, federal and state financing, and other characteristics that remain to be measured.
Definitions of residential settings
The discussion below is excerpted from Census documents, revised for the present purpose.
A household consists of all the people who occupy a housing unit. A housing unit may be a house, an apartment, a mobile home, a group of rooms or a single room that is occupied as separate living quarters. Separate living quarters are those in which the occupants live separately from any other individuals in the building and which have direct access from outside the building or through a common hall. Boats, recreational vehicles (RVs), vans, tents, railroad cars, and the like are included only if they are occupied as someone's current place of residence. Occupants may be a single family, one person living alone, two or more families living together, or any other group of related or unrelated people who share living quarters. Occupied rooms or suites of rooms in hotels, motels, and similar places are classified as housing units only when occupied by permanent residents, that is, people who consider the hotel as their current place of residence or have no current place of residence elsewhere.
If any of the occupants in rooming or boarding houses, congregate housing, or continuing care facilities live separately from others in the building and have direct access to their housing unit, their units are classified as housing units and the occupants are classified as households.
A household includes related family members and all unrelated people, if any, such as lodgers, foster children, wards, or employees who share the housing unit. A person living alone in a housing unit, or a group of unrelated people sharing a housing unit such as partners or roomers, are also counted as households.
A group setting is a place where people live or stay that is normally owned or managed by an entity or organization providing housing and/or services for the residents. These services may include custodial or medical care as well as other types of assistance, and residency is commonly restricted to those receiving these services. People living in group settings usually are not related to each other. Group settings include such places as college residence halls, residential treatment centers, skilled nursing facilities, group homes, military barracks, correctional facilities, and workers' dormitories.
Institutions include facilities for people under formally authorized, supervised care or custody at the time of interview, such as correctional facilities, nursing facilities/skilled nursing facilities, in-patient hospice facilities, mental (psychiatric) hospitals, group homes for juveniles, and residential treatment centers for juveniles.
Noninstitutional group arrangements include facilities that are not classified as institutions, such as college/university housing, group homes intended for adults, residential treatment facilities for adults, workers' group living quarters and Job Corps centers, and religious group quarters. A complete description of the types of group quarters included in the ACS is located on the U.S. Census Bureau's Internet site at http://www.census.gov/acs/www/UseData/GQ/def.htm