NCHS Data Brief ■ No. 25 ■ December 2009

u.s. department of health and human services

Centers for Disease Control and Prevention

National Center for Health Statistics

Racial Differences in Functioning Among Elderly Nursing 

Home Residents, 2004

Adrienne L. Jones; Nancy L. Sonnenfeld, Ph.D.; and Lauren D. Harris-Kojetin, Ph.D.

Division of Health Care Statistics

Key findings

•	 Black nursing home 

residents had poorer functional 

status than residents of other 

races.

•	 Black residents were more 

likely to be totally dependent 

in both eating and toileting 

and to be totally dependent 

in all five activities of daily

living.

•	 Black nursing home 

residents were more likely 

to be incontinent of bladder, 

bowel, or both.

•	 Among bladder-incontinent 

nursing home residents, black 

residents were less likely than 

those of other races to have

scheduled toileting plans.

Reducing racial disparities in health care is an important national policy 

goal. Previous research on racial disparities has focused on nursing home

placement rates. Recent research suggests that black nursing home residents 

may be more likely than residents of other races to reside in facilities that 

have serious deficiencies, such as low staffing ratios and greater financial

vulnerability (1,2).

In 2004, 11% of the 1.3 million nursing home residents aged 65 and over in

the United States were black. National descriptions of black nursing home 

residents are limited. Using data from the most recent National Nursing 

Home Survey, this report highlights differences observed between elderly

black nursing home residents and residents of other races in functioning 

and resident-centered care. The specific measures highlighted are functional

status, incontinence, and management of incontinence.

Keywords: Racial disparities • Activities of daily living and functional status • 

Incontinence management and scheduled toileting plan

Black residents had lower functional status.

87

66 66

53

29

85

63 61

52

24

0

10

20

30

40

50

60

70

80

90

100

Bathing Dressing Toileting2 Transferring Eating2

Adjusted percentages Black Other races 1

1

Percentages were adjusted for age and sex.

2

Statististically significant difference (p<.05).

SOURCE: CDC/NCHS National Nursing Home Survey.

Figure 1. Elderly nursing home residents totally dependent in activities of daily living by race: 

United States, 2004
NCHS Data Brief ■ No. 25 ■ December 2009

■  2  ■

Activities of daily living (ADLs) are everyday routines generally involving functional mobility

and personal care. Difficulty with, or inability to perform ADLs can be used to measure a person’s

level of physical functioning or disability. Black nursing home residents were more likely to be

totally dependent in eating (29 percent compared with 24 percent) and toileting (66 percent

compared with 61 percent) than residents of other races (Figure 1). There were no significant

differences in the other three ADLs (bathing, dressing, and transferring). Black nursing home

residents were also more likely to be totally dependent in all five ADLs (59 percent compared

with 51 percent) than residents of other races (Figure 2).

59

51

0

10

20

30

40

50

60

Five activities of daily living2

Black Other races Adjusted percentages1

1

Percentages were adjusted for age and sex.

2

Statististically significant difference (p<.05).

SOURCE: CDC/NCHS National Nursing Home Survey.

Figure 2. Elderly nursing home residents totally dependent in all five activities of daily living, by race: United States, 2004
NCHS Data Brief ■ No. 25 ■ December 2009

■  3  ■

Black residents were more likely to be incontinent. 

The percentage of black nursing home residents (70 percent compared with 63 percent) with any

incontinence was significantly higher than residents of other races (Figure 3). The percentage of

black nursing home residents with bladder incontinence (67 percent) was higher than residents of

other races (60 percent); the percentage of black nursing home residents with bowel incontinence

(59 percent) was significantly higher than residents of other races (47 percent); and the percentage

of black nursing home residents with both bladder and bowel incontinence (55 percent) was

also higher than the percentage of residents of other races with both types of incontinence (43

percent).

70 67

59

55

63

60

47

43

0

10

20

30

40

50

60

70

80

Any incontinence2 Any bladder

incontinence2

Any bowel

incontinence2

Bladder and bowel

incontinence2

Adjusted percentages Black Other races 1

1

Percentages were adjusted for age and sex.

2

Statististically significant difference (p<.05).

SOURCE: CDC/NCHS National Nursing Home Survey.

Figure 3. Elderly nursing home residents with incontinence by race: United States, 2004
NCHS Data Brief ■ No. 25 ■ December 2009

■  4  ■

Bladder-incontinent black nursing home residents were less likely to have 

a scheduled toileting plan.

Nursing home residents with bladder incontinence may benefit from a scheduled toileting plan―a

noninvasive intervention involving the resident and caregiver that can improve continence or

assisted continence (3). Among bladder-incontinent nursing home residents, black residents were

less likely than residents of other races (20 percent compared with 26 percent) to have scheduled

toileting plans (Figure 4).

20

26

0

5

10

15

20

25

30

35

Scheduled toileting plan2

Black Other races Adjusted percentages1

1

Percentages were adjusted for age and sex.

2

Statististically significant difference (p<.05).

SOURCE: CDC/NCHS National Nursing Home Survey.

Figure 4. Bladder-incontinent elderly nursing home residents with a scheduled toileting plan by race: United States, 2004 
NCHS Data Brief ■ No. 25 ■ December 2009

■  5  ■

Summary

In 2004, elderly black nursing home residents in the United States were more likely to be

functionally impaired and incontinent compared with residents of other races. Black nursing 

home residents were more likely to be totally dependent in two ADLs―eating and toileting,

but there were no differences by race in three other ADLs―bathing, dressing, and transferring.

The most notable difference in functioning between black nursing home residents and those of 

other races was the larger proportion of black nursing home residents totally dependent in all five

ADLs. Black nursing home residents were also more likely to be incontinent of bladder, bowel,

or both. Black residents who were bladder incontinent were also less likely to have a scheduled

toileting plan, one approach for treatment of bladder incontinence. These data identify important 

differences in the needs and care of black nursing home residents nationally.

Definitions

Activities of daily living: Personal care activities necessary for everyday living, such as bathing,

dressing, eating, transferring, and toileting; a term often used by health care professionals to

assess the need or type of care a person may require (bathing, dressing, eating, transferring, and

toileting).

Incontinence: Bladder incontinence is the inability to control the passage of urine. Bowel 

incontinence is the inability to control the leakage of stool. For this study, a resident who had

inadequate control all of the time in the last 14 days was considered incontinent.

Other races: Include white, Asian, Native Hawaiian or Other Pacific Islander, American Indian or

Alaska Native, and multiple races.

Scheduled toileting plan: A plan to improve continence or assisted continence that may include

such things as prompted voiding (reminding an individual to toilet at appropriate and scheduled

times during the day), scheduled voiding on a specific schedule, or walking an individual to the

bathroom and giving verbal or visual cues to use the toilet.
NCHS Data Brief ■ No. 25 ■ December 2009

■  6  ■

Data source and methods

The 2004 data are the most recent data collected for the National Nursing Home Survey. Data

were analyzed for 11,900 black residents and other races aged 65 and over residing in 1,174

nursing homes representing 1,317,300 residents nationally, from the 2004 National Nursing Home

Survey (NNHS). NNHS is a periodic cross-sectional survey of a nationally representative sample

of U.S. nursing homes. It is designed to provide descriptive information on nursing homes,

their services, their staff members, and the residents they serve. NNHS was first conducted in

1973–1974 and repeated in 1977, 1985, 1995, 1997, 1999, and most recently 2004.

The sample design for the 2004 NNHS was a stratified, multistage probability design. The first

stage was the selection of facilities, and the second stage was the selection of residents. The 

primary sampling strata of facilities were defined by sampling bed size category and metropolitan

statistical area status. For the 2004 NNHS, 1,500 nursing homes were selected using systematic

sampling with probability proportional to their bed sizes. The second stage sampling of up to 12

current residents was carried out by the interviewers at the time of their visits to the facilities.

The sampling frame for current residents was the total number of residents on the register of the 

facility as of midnight the day before the survey.

All percentages were adjusted using logistic regression for differences in the age and sex 

distributions between black residents and other races. All differences presented are statistically 

significant (p<.05).

About the authors 

Adrienne L. Jones, Nancy L. Sonnenfeld, and Lauren D. Harris-Kojetin, are with the Centers for

Disease Control and Prevention’s National Center for Health Statistics, Division of Health Care

Statistics.
NCHS Data Brief ■ No. 25 ■ December 2009

■  7  ■

References

1. Smith DB, Feng Z, Fennell ML, Zinn JS, Mor V. Separate and unequal: racial segregation and

disparities in quality across U.S. nursing homes. Health Aff 26(5):1448–58. 2007. Erratum in:

Health Aff 26(6):1794. 2007.

2. Mor V, Zinn J, Angelelli J, Teno JM, Miller SC. Driven to tiers: socioeconomic and racial

disparities in the quality of nursing home care. Milbank Q 82(2):227–52. 2004.

3. Durrant J, Snape J. Urinary incontinence in nursing homes for older people. Age and Aging

32:12–8. 2003.
NCHS Data Brief ■ No. 25 ■ December 2009

U.S. Department of

Health & Human Services

Centers for Disease Control and Prevention

National Center for Health Statistics

3311 Toledo Road

Hyattsville, MD 20782

Official Business 

Penalty for Private Use, $300

To receive this publication regularly, contact the

National Center for Health Statistics by

calling 1–800–232–4636

E-mail: cdcinfo@cdc.gov

Internet: http://www.cdc.gov/nchs

First Class mAIL

Postage & Fees Paid 

CDC/NCHS

Permit No. G-284

ISSN 1941-4927 (Print ed.)

ISSN 1941-4935 (Online ed.)

CS208112

T35465 (12/2009)

DHHS Publication No. (PHS) 2009–1209

Suggested citation

Jones AL, Sonnenfeld NL, Harris-Kojetin

LD. Racial differences in functioning among

elderly nursing home residents, 2004. NCHS

data brief, no 25. Hyattsville, MD: National

Center for Health Statistics. 2009.

Copyright information

All material appearing in this report is in 

the public domain and may be reproduced 

or copied without permission; citation as to

source, however, is appreciated.

National Center for Health 

Statistics

Edward J. Sondik, Ph.D., Director

Jennifer H. Madans, Ph.D., Associate 

Director for Science

Division of Health Care Statistics

Jane E. Sisk, Ph.D., Director