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STATEMENT OF DR. T. FRANKLIN WILLIAMS

I am pleased to be able to present to you accomplishments recently achieved by the research programs of the National Institute on Aging (NIA), as well as outline current plans and the directions charted for future research. We work to coalesce scientific opportunities in order to address major challenges in aging and the critical national needs to alleviate suffering, disability, and medical expenditures. But more importantly, our research is crucial for keeping these problems from increasing in magnitude with the "graying" of America. Demographically, America is predicted to experience marked growth in the older age groups because of the maturation of the baby boom generation, and also potentially because of beneficial changes in the personal lifestyle of Americans, including a more healthy diet, increased exercise, and a reduction in smoking. The demonstrated fact that older adults can age and remain healthy highlights the challenging need to identify and reduce health risks leading to disease, disability and resulting long-term care requirements.

NIA-supported studies on aging have evolved to a higher level of intensity; now more than ever we are presented with the opportunity to promote independence and reduce disability in later life.

Statistics on the growth of the older population tell a compelling story: currently, more than 30 million persons are over 65 years of age; about 3 million are over 85 years of age. This over-85 group, whom we often call the "oldest old," is the fastest growing segment of the American population: in 1987 medical expenses for this oldest old group averaged $9,178 per person with Medicare contributing over a third of that cost, compared to $3,728 per person in the age 65 to 69 group. Unless we can develop, through research and its benefits, means to prevent and effectively treat the major causes of disability in old age, the total cost of care for just those aged 85 and more are projected to rise in real dollars from the $9.2 billion spent in 1987 to over $50 billion in the year 2040. NIA's ultimate goals of research are to assure independence and a high quality of life throughout the life span.

As one of the highest priorities for the NIA, research on Alzheimer's disease will be supported at a level of $155 million in FY 1992. This disease is currently responsible for disability and misery in up to four million Americans and their families, costing them and society as a whole well over

$80 billion in direct health care and other costs annually. The prevalence of dementia, the most common form of which is Alzheimer's disease, increases with age; some recent estimates indicate that up to 47% of those over age 85 are

afflicted.

The marked growth over the next 50 years of the older population may result in up to a five-fold increase in dementia patients along with

associated health-care costs.

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We have made significant progress in understanding this disease. Researchers investigate and learn more about the biochemical defects responsible for the diagnostic hallmarks of Alzheimer's disease--the amyloid plaques and the neurofibrillary tangles within the brain. A recent finding shows that a fragment of the amyloid protein molecule, which may support the growth of nerve cells at low concentrations, has at higher concentration a major toxic effect upon nerve cells. Also, genetic studies will continue to develop information on the association between two subtypes of Alzheimer's disease and genes located on chromosomes 19 and 21.

Regarding progress in treatment, we recently completed the patient accrual/data gathering phase of an important clinical trial, conducted within our Alzheimer's Disease Research Centers and at other sites, of the drug known as THA. It is expected that results will soon be published and available to the scientific and medical community. This well designed and executed study has already begun to serve as a model for future trials of new promising agents. We also concentrate efforts on more accurately diagnosing and assessing the progress of Alzheimer's. Special effort is being made to find positive markers of the disease, using innovative techniques from molecular biology to search for abnormalities in non-neural tissue. Researchers are

also utilizing sophisticated imaging techniques to improve the diagnostic utility of MRI, PET, and CT scanning. This will allow for differentiation between early stage Alzheimer's and other neurological and psychiatric illnesses and better ensure correct treatment of the patient's condition.

The burden of care for the Alzheimer patient is tremendous--financially, emotionally, and physically. Our substantial research in long term care demonstrates that such burdens often make the caregivers "hidden patients," often needing outside assistance and support to maintain their own health and functioning. We have just released a new request for grant applications to

develop more information on long-term care issues, asking for systematic studies of the benefits of specialized care units on dementia patients, family members, and health care administrators and practitioners.

These and other new developments in Alzheimer's disease research are among those highlighted in the recently released second report of the Congressionally appointed Advisory Panel on Alzheimer's Disease.

The panel

has emphasized the need and opportunity for further progress in understanding and treating Alzheimer's disease--progress that can come from a significant research effort on this dread disorder.

Older persons must also face the consequences of possible physical frailty. A major goal of the NIA is to develop interventions to minimize loss of function and to maintain independence at the maximum level possible. The costs of physical frailty are comparable to those imposed by dementia.. estimates range from $54 billion to over $80 billion per year, including $24 billion for health-related services alone. Frailty can extract such costs through fall-related injuries, including hip fracture, and through the consequential loss of one's ability to live independently.

As with dementia, the prevalence of affliction is especially concentrated among the oldest old. But it is increasingly evident that people are never "too old" for prevention or reduction of physical frailty. It is a particularly fruitful research focus because frailty interventions, such as leg strengthening exercises, balance training, and modification of medication dosage, have either been tested or are now ready for testing. As reported in June 1990, a notable NIA-supported study of muscle strengthening exercises in frail 90 year-old persons showed remarkable improvement in muscle strength, muscle mass, and the ability to walk. Such an approach is at the heart of geriatric care; NIA shares this philosophy on comprehensive rehabilitation with the new National Center for Medical Rehabilitation Research.

A series of clinical trials to gather definitive information regarding prevention or reversal of frailty was initiated in 1990 and will continue through 1993, including a special initiative on frailty in minority populations. At this point we will choose the most successful elements from the trials to develop a comprehensive strategy for reducing frailty, falls, and other injuries. Another important step toward better integrated geriatric

care occurred with the 1990 amendment of the Public Health Service Act

authorizing creation of Claude D. Pepper Older Americans Independence Centers. Because independence is the central focus of the centers, these studies will consider the full range of older persons' physical and mental functional abilities, not just the effects of treatment on a particular disease. These centers also provide an excellent environment for imparting to health care professionals strategies for how to put these various frailty interventions to use. NIA plans to fund up to four of these Centers in FY

1991.

Early retirement is one more issue that we must face as a society as it is now costing the nation an estimated $15-20 billion annually in lost earnings, lost taxes, reduction in saving rates, and other related costs. This continuing trend toward younger retirement has enormous social and fiscal implications. As directed by Congress, the NIA has initiated and with other Federal agencies will continue to support the Health and Retirement Survey. This survey is designed to provide current data upon which to project possible social and fiscal impact from changing demographics and other factors on issues such as the Social Security earnings test, the age for eligibility for Social Security and Medicare benefits, and the design of private pension plans. Already, the NIA has compiled a substantial body of findings on the positive effect of continued work activity on productivity, health, and intellectual functioning.

Another priority area for NIA is sponsorship of cardiovascular research, particularly how both "normal" aging as well as disease states in the older population affect changes in the cardiovascular system. Because the onset of cardiovascular disease in adults can be delayed into later years through present prevention interventions, it is imperative that we develop additional knowledge on cardiovascular disease within older persons. While we have made some advances in this area, a better understanding of vascular aging and its relationship to vascular disease should lead to answers to why arteries become stiff and more prone to atherosclerotic disease with advancing age. Ultimately this could lead to the development of "age-adjusted" therapy for hypertension and atherosclerosis.

The NIA will continue to emphasize aging research on issues particularly

relevant to women's health such as osteoporosis, post-menopausal estrogen replacement therapy, and urinary stress incontinence. As requested, a report concerning research on women's health has been prepared and will be available to the Committees. Studies of other subgroups of older Americans, including rural populations and ethnic minority populations, will continue to receive special attention by the National Institute on Aging. For example, it is important to be able to recognize that differences exist in the use of health care services among populations, and how such differences affect health care delivery systems.

Basic research studies into the biological and behavioral mechanisms of the aging process will continue into 1992. An understanding of these basic mechanisms will aid in identifying appropriate interventions to prevent disease and disability, as well as learn what ideally could be expected for "normal" aging. For example, we have learned that within each cell, a balance exists between genes that "turn on" cell reproduction, called proliferative genes, and those that "turn off" reproduction referred to as antiproliferative genes. Disruption of this balance leads to an inability to reproduce--which occurs in aging cells--or to uncontrolled proliferation--as seen in cancer celis.

Scientists supported by the NIA are studying genes that block cell proliferation in senescent cells. Knowledge gained from these studies of senescent cells will be of enormous value in our understanding aging processes and age-related diseases, including cancer.

Regarding behavioral research, studies have shown that reduction in the visual field of vision is actually amenable to training. Poor performance in the field of vision test is strongly associated with older adults involved in driving accidents, especially at intersections. Through development of training interventions, there is now optimism that accidents can be reduced in older drivers, thus enabling older adults more years of safe driving. Further research, including hearing studies, should enable the development of other interventions to ameliorate loss of function and independence.

The NIA is actively supporting research on aging and sleep, and provides key support for the Congressionally created National Commission on Sleep Disorders Research. Because so many older persons have disturbances in sleep patterns, it is commonly assumed that loss of sleep patterns is simply part of

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