48 percent was verbal, and 4 percent sexual. Aggression was correlated with functional dependence, although no category correlated with cognitive impairment.

Perhaps most difficult to deal with in nursing homes are the interactions among residents, some of which are positive and encourage friendships, while others are negative and involve violent arguments and even physical fights. Jones (1975) studied 441 residents in 10 intermediate care nursing homes and found that spatial proximity is an important consideration in the analysis of social interaction between residents. Arguments and fights occurred more frequently in fairly restricted spatial arrangements (e.g., 4-bed rooms), while friendship interactions were more likely to occur between residents who resided at least 2-rooms' distance from one another. The results suggest that in the limited environment of the nursing home both closeness and distance are needed for positive interactions among residents.

It is estimated that 22 percent of the elderly long-term-care population live in nursing homes and other facilities, whereas 40 percent or more live at home with a spouse. The elderly are at higher risk for physical and mental health problems, impaired coping, functional decline, and premature institutionalization than the general population (Preston and Mansfield, 1984). These risks are even greater for the elderly who live alone and in poverty, particularly women (Krout, 1986).

Public expenditures for community-based services are relatively small compared to those for nursing home care (O'Shaunessy and Price, 1987). Medicaid, which is the principal source of funding of health care services for low income persons, finances mostly nursing home care. Expenditures for institutional long-term care in 1993 are estimated to be $74.9 billion. (Of that amount $36.9 billion were from Medicaid and $4.8 billion were from Medicare.) (DHHS, 1993).

Nevertheless, there is concern about underuse of nursing home care by some elderly, especially in areas where there are fewer nursing home beds per capita of elderly in the population. In general, rural areas have a higher concentration of the elderly and higher rates of chronic illness and disability. The growing number of older citizens in rural areas is especially pronounced in the Midwest and South. Yet the number of available nursing home beds—whether in traditional nursing homes or alternatives such as in-home care—is less per capita in these areas than in urban areas, and the shortage of RNs is greater in rural areas and in areas where the more impoverished elderly reside (Select Committee on Aging, 1992). Although Medicaid pays at least some of the costs of care for about 60 percent of nursing home patients, efforts by states to control costs of Medicaid have tended to limit the supply of nursing home beds. Further, the lack of Medicare reimbursement and the spend-down requirements to qualify for Medic-