are learning that people are never too old to prevent or reduce frailty. NIA is supporting tests of ways to improve strength and prevent disabling falls through its Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT) program. NIA will begin testing interventions which could prevent osteoporotic hip fractures under the Sites Testing Osteoporosis Prevention/Intervention Treatments (STOP/IT) program in FY 1991, but resources will not permit tests of all promising interventions. In FY 1991, NIA will also initiate research on special problems of frailty among minorities. Other promising directions need study, such as use of growth hormone and other trophic factors against degenerative diseases, reduction of disability from cardiovascular disease and osteoarthritis, prevention of automobile driving disabilities, and behavioral factors in maintaining fitness in the older population. Current support for these research directions is now far outweighed by opportunity as reflected by the numbers of excellent unfunded grant applications.

An information clearinghouse on fitness and independence for older Americans would give the public better access to information about ways to prevent or reduce physical frailty and disability.

QUESTIONS SUBMITTTED BY SENATOR ARLEN SPECTER

GERIATRIC PHARMACOLOGY

Question. Dr. Williams, a number of Congressional hearings have highlighted severe health problems which have been associated with inappropriate drug prescriptions for older persons. Has the Institute examined the nature and extent of this problem? In your judgment, what needs to be done to seriously address this problem?

Answer. A panel convened by NIA and the Institute of Medicine reviewed data confirming that inappropriate drug prescribing for older persons often causes serious health problems. Adverse drug effects contribute to one in eight hospitalizations of older persons (over one million per year) costing at least $3 billion annually. Nonhospital costs from adverse medication effects are also very large.

One key step needed to address this problem is improvement in drug prescribing for older persons. An NIA-supported study conducted in Nashville illustrates the dramatic potential of this approach. It showed that use of some tranquilizers, but not others, was associated with higher rates of falling leading to hip fractures in older persons. This information could be translated directly into better drug prescribing. As one of their funded activities, NIA's Claude D. Pepper Older Americans Independence Centers will support education and information transfer projects targeted towards public as well as professional audiences. Information transfer related to better drug prescribing for older persons, including more effective avoidance of drug interactions, would be within the scope of such activities. Furthermore, the establishment of an NIA Information Clearinghouse on Fitness and Independence for Older Americans could serve such a function at the national level. Better dissemination to prescribing

physicians of existing knowledge of medication effects in older persons would help reduce this problem.

However, more information on geriatric pharmacology is also critically needed. For fiscal year 1991, NIA issued a Request for Applications on geriatric pharmacology, aimed at better medication use for older persons. NIA received 114 applications and was able to fund 12 of these projects, including two clinical trials of techniques to improve drug prescribing, and several studies aimed at improving current drug therapy and identifying adverse effects.

We

Though these projects are a significant beginning, the current extent of research only addresses a small fraction of undiscovered drug effects and interactions in older persons. also need research-based guidelines for the withdrawal of medications from older persons, so that only those medications required are continued. Since multiple medication use is so common among older persons, expanded efforts in these areas are needed.

Perhaps even more fundamentally, we need better medicines which will not have the adverse effects of many drugs currently used for health problems of older persons. Treatments which could correct underlying age-related debilitating conditions rather than merely their symptoms could increase benefit and lessen risk.

A particularly promising prospect is the use of trophic factors such as growth hormone. Trophic factors are hormones and other factors in the body which promote growth or maintenance of tissues. Interest is rapidly increasing in their potential to arrest or reverse degenerative changes in bone, muscle, nerves, and cartilage which lead to frailty and dependence. A recent short-term study in Chicago and Milwaukee, showing that growth hormone reverses such changes in certain older subjects who have low levels in their blood, raised the issue of a "fountain of youth" in the more sensational press. While growth hormone is clearly no such panacea, and much more testing is needed to determine its clinical value and safety, the excitement over this study captures trophic factors' great potential for fundamental progress against degenerative conditions long considered inevitable with advancing age. Possibilities for additional research are rapidly expanding and need to be pursued,

particularly because clinical tests as well as laboratory studies are now feasible.

NATIONAL INSTITUTE ON ARTHRITIS AND MUSCULOSKELETAL, AND SKIN DISEASES

STATEMENT OF DR. LAWRENCE D. SHULMAN, DIRECTOR

BUDGET REQUEST

Senator HARKIN. The subcommittee will resume its sitting. Dr. Shulman, welcome back. It is always a pleasure to see you and have an opportunity to learn more about the Institute and its research programs. I understand that April 16 is the fifth anniversary of the founding of the National Institute on Arthritis, Musculoskeletal, and Skin Diseases. I must congratulate you on the tremendous contribution the Institute has made these past 5 years, both to the scientific research community and to those who suffer from these chronic diseases. Although much has been accomplished during this time, I know that you feel there is still much to be done.

I see that the Institute's 1992 budget request is $204.8 million, an increase of 6 percent over last year's appropriation.

Could you please briefly summarize the Institute's five science programs and highlight your plans for fiscal year 1992 in these areas, Dr. Shulman?

Dr. SHULMAN. Thank you so much, Mr. Chairman.

Mr. Chairman, our Institute is having a very good year this year. We are supporting some exceptional research with some key discoveries. We have had excellent workshops, new developments in our intramural program, and we are developing new initiatives, as you and we have identified them this past year.

Prevention is the key. We agree with you on that point.

We work on diseases that concern women's health, minorities, and rare diseases as well. We have many of the diseases in that rare disease category that we are interested in.

OSTEOPOROSIS

However, let's start off with osteoporosis, for which, as you know, we are the lead Institute. We have had much progress this year in osteoporosis, but we have a great deal more to do. We prepared a major report for the Department to submit to you on osteoporosis. I demonstrate it here. It is a very fine report, and we are pleased to have had the privilege of doing it. Many suggestions for the future research are in that report.

In response to your request for special emphasis in this area in the amount of $6 million during the current year, we have issued two requests for applications, one for basic research on causal mechanisms on osteoporosis, and the second on clinical and epidemiological research. We have also joined with the Aging Institute

in another request for applications in interventions in the elderly who have osteoporosis.

In the meantime, we have had some research advances in osteoporosis. A key one, as you know, are the bisphosphonates which are used to retard bone loss in post-menopausal women. It provides an alternative to estrogen replacement therapy, which has been confirmed once again as being valuable. We need to find the best type of hormone combinations for that effort.

Calcium is important at all ages. Let me indicate that we have had a very interesting study this year in young twins, children. Some twins have been taking the ordinary amount of calcium that children are supposed to take; their twin pairs have taken a supplement of twice that much. Those who have taken the supplement have built up more dense bones than the others who have taken the ordinary amount.

We have had a study report in the New England Journal of Medicine of women who are not producing the normal amount of hormones during their twenties, thirties, and forties; they have lower bone mass than other women who menstruate normally.

We have also had studies showing that running in the elderly may actually be helpful.

The right amount of exercise is a problem not only for all of us, but especially for our astronauts.

Senator HARKIN. Excuse me. Did you say running?

Dr. SHULMAN. Older people running. It is good for them, good for their bones.

Senator HARKIN. Thank you. Now, I have it clear in my head. It is good for older people to run. All right. [Laughter.]

Dr. SHULMAN. It's good for their bones. This is a problem for our astronauts. If we are going to go to Mars, either with or without the Soviets, we have to be sure that the astronauts don't lose much of their bone mass. So, we are working with NASA on this.

LYME DISEASE

Another area of importance that has interested both you and us is Lyme disease. We appreciate that this disease is still spreading. Last year, as you know, we issued a request for applications on causal mechanisms. With your special emphasis this year, we have responded with another request for applications, this time for research on the diagnosis and treatment of Lyme disease, both of which are still problems. We have keen problems in the diagnosis of Lyme disease. There is difficulty in defining it with great accuracy, and we do not have fully reliable laboratory tests. Various tests do not agree with one another, according to a study done by the CDC and as reported at a conference last fall.

There seems to be both underdiagnosis and overdiagnosis in endemic areas. So, this is another type of problem. And certain outdoor workers, such as forestry workers, are actually at special risk, and we need to have preventive modes for them.

OSTEOARTHRITIS

We have had exceptional discoveries in two areas. The first is osteoarthritis, the most common form of arthritis usually occurring in