high-risk behaviors related to the transmission of HIV and prevention strategies for women and minority populations.

RESEARCH TRAINEES

Question. Dr. Hinshaw, you are showing a decrease in the number of research trainees for the first time after several years of growth. The nursing community has expressed the need for continued growth in research training for nurses. Is this area no longer a priority for NCNR?

Answer. Research training remains a high priority for the

NCNR. There is a strategic plan for systematically increasing the number of supported trainees and fellows to 320 per year. This number is based on the recommendation of the Institute of Medicine 1985 report on Personnel Needs and Training for Biomedical and Behavioral Research. By FY 1990, the number of supported trainees/fellows had increased from 165 in FY 1986 to 257. However, in 1992, in order to increase funds for research project grants, it is not possible to continue to raise the number of individuals supported for research training.

NURSING RESEARCH ON OLDER PERSONS

Question. Are there specific research studies NCNR is supporting that will lead to improved nursing care for your Nation's older people?

Answer. As the proportion of older persons continues to increase, NCNR has recognized the need for understanding their changing health problems and for well designed and effective nursing intervention strategies to assist with these health problems. NCNR research on older persons addresses their health behaviors in order to increase their ability to stay well, to decrease the impact of chronic illness, to avoid disabilities from declining functional status, and to assist in maintaining their quality of life. The NCNR also funds research on caregiving issues concerning older people who are experiencing health problems such as Alzheimer's disease, cancer, and cardiac disease.

Examples of research studies include nursing interventions to deal with the problem of urinary incontinence, to increase proper medication adherence in older persons with rheumatoid arthritis, to evaluate methods that enhance recovery from a myocardial infarction in older women, to improve breast cancer screening, and to improve respiratory status for persons with chronic obstructive lung disease. Other studies are examining the convalescence and return of functional ability of older women with hip fractures and the role exercise training can play in recovery following stroke.

NCNR has targeted long-term care research as a priority area. During FY 1991, NCNR will initiate a research program focused on community-based long-term care of older persons. As most older persons live in the community and do not need long-term care in a nursing home, this research program will encourage investigators to develop intervention strategies to assist in maintaining sound health status, to increase well being, and to enable older individuals to remain at home rather than being institutionalized when they become ill or impaired.

QUESTIONS SUBMITTTED BY SENATOR DANIEL K. INOUYE

ALZHEIMER'S DISEASE

Question. As you know, Congress has great interest in research related to Alzheimer's Disease and that the NCNR has been an active partner is addressing this important issue. Do you have any new initiatives to contribute to our knowledge of caring for individuals with this devastating illness?

Answer. Alzheimer's Disease and the related dementias (AD) are certainly a significant and growing health problem. The impact of AD on the over 4 million Americans afflicted with the disease and their families is severe. Although it is not yet possible to prevent, treat, or permanently alter the course of the underlying disease, interventions are being developed and tested which can help to manage the symptoms and preserve function.

In addition to research on the caregiving aspects of Alzheimer's disease, the NCNR portfolio includes studies related to the clinical management of patient and family responses to symptoms experienced by patients. Interventions are being tested to deal with symptoms such as cognitive deficits, aggressive behaviors during activities of daily living, and spatial memory disturbances and disorientation which often result in wandering behaviors.

In order to stimulate research in this area, an RFA entitled, "Management of Alzheimer's Disease Symptoms," has been issued in collaboration with the National Institute on Aging for preliminary investigations dealing with the broad range of secondary symptoms exhibited by Alzheimer's patients. The symptoms may include, but are not limited to wandering, disturbed sleep, pacing, agitation, feeding and dressing difficulties, incontinence and toileting difficulties, screaming and other vocalizations, aggression, and violence. These symptoms not only contribute to decisions to institutionalize affected individuals, but also lead to the use of chemical and physical restraints.

Data from these studies will provide valuable information on the acceptability, safety, and rationale for the effectiveness of the interventions needed prior to undertaking any large scale clinical trials.

COLLABORATIVE RESEARCH

Question. Dr. Hinshaw, as you know, Congress is interested in each of the NIH Institutes working collaboratively with the NCNR. What are some examples of interdisciplinary initiatives/activities that are ongoing/underway? NIA; Frailty-NIA; Adherence-NHLBI; Diabetes-NIDDK; LBW-NICHD; P20NICHD/NIMH)

(Alzheimer's

Answer. NCNR continues to work collaboratively with several NIH Institutes. The initiatives regarding care and prevention of low birthweight infants have been cosponsored by the National Institute of Child Health and Human Development. NCNR continues to work with the National Institute on Aging in support of

research on the management of symptoms experienced by Alzheimer's disease patients. The National Institute of Diabetes and Digestive and Kidney Diseases and the NCNR are co-sponsoring a request for applications for studies on diabetes in minority populations. Two other Institutes (NICHD & NIMH) have joined NCNR in a request for applications for an exploratory center grant initiative targeted to investigations of health behavior development in children and adolescents.

Because nursing research cross-cuts so many disease areas, NCNR staff are constantly watching for viable research opportunities that may be of interest to other NIH Institutes, Centers, or Divisions for possible cofunding opportunities.

In FY 1990, funds totaling $1.6 million were received from other agencies for cofunded projects. NCNR will continue to work with colleagues in other Institutes to foster interdisciplinary research.

LONG-TERM CARE

Question. A recent New England Journal of Medicine (Feb 28, 1991) article projects that of persons who turned 65 in 1990, 43% will enter a nursing home before they die. Is NCNR supporting any studies to improve the quality of care in nursing homes?

Answer. Concern about the quality of care in nursing homes has been an ongoing interest of NCNR and the nursing research community. Recognizing that with the increasing growth of the elderly population the numbers of older persons requiring some time as a nursing home resident will also increase, NCNR has targeted long-term care as a priority area. Several studies have been funded by NCNR that focus on the development and evaluation of specific intervention strategies for nursing home residents. In one such study, an investigator is examining the effectiveness of a dressing behavior intervention designed to maintain functional independence among cognitively impaired nursing home residents as long as possible. Preliminary information from this study has enabled this investigator to expand the work to other behavioral strategies that could assist demented older persons.

Another investigator who is investigating factors that influence recovery from hip fractures, has followed patients from the hospital to nursing homes or to home care. Preliminary analysis shows that increased age, the presence of more than one health problem, ability to be mobile after surgery for the fracture, and whether or not the patient lived alone influenced return to full functional status and admission to a nursing home. A third investigator has designed a nursing intervention for nursing home residents at risk for declining functional status and is evaluating its effectiveness in adverting this decline among residents.

As some of the intervention studies have been completed new areas for investigation have been identified. One such intervention study was targeted toward one of the more difficult care problems occurring in nursing homes, urinary incontinence. In this study a regimen of prompted voiding as a strategy to

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increase continence was examined and found to be successful for a considerable number of residents. However, the success of this intervention requires the full attention and motivation of nursing home staff to maintain the regimen which was not forthcoming once the investigative team withdrew after the study was completed. new area of possible inquiry for the investigator is to examine ways to effectively implement interventions that are experimentally successful but not as effective in clinical practice.

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Long-term care will continue to be a priority for NCNR. important area for emphasis will be the examination of ways to facilitate the transition of older persons in nursing homes back to successful community living. Studies that focus on interventions to maintain and improve functional abilities, avoid the onset of disabilities, and to maintain the health of those with chronic illnesses should assist in delaying, or avoiding the need for, nursing home care among older persons in the future.

QUESTIONS SUBMITTTED BY SENATOR DALE BUMPERS

HEALTH PROMOTION:

ADOLESCENTS AND CHILDREN

Question. I understand that the Center for Nursing Research is collaborating with other institutes on an initiative to study adolescents and risky health behaviors. Can you tell us more about that?

Answer. Several recent reports highlight the significance of behaviors which compromise health. These patterns of behaviors including diet, physical activity, alcohol and tobacco use, risk taking, and sexual behaviors begin in childhood and adolescence. Little is known about the natural history of such behaviors. Healthy alternatives to meeting the needs of adolescents need to be identified and tested. In collaboration with other funding agencies, NCNR is seeking research that will form the foundation for testing theory based interventions critical for nurses and other health professionals working with children in schools and other settings that encompass knowledge of behavior, learning, and psychological and cognitive development.

RESEARCH TRAINEES

Question. When the NCNR was created, this subcommittee hoped that the center would help foster a strong supply of nurse researchers. What can you tell us about the numbers of nurse researchers who are applying for support from NCNR? Are there other actions this subcommittee should take to ensure that nurses enroll in doctoral programs and have sufficient support and encouragement to seek a career in research?

Answer. A major initiative of the NCNR is to develop a strong cadre of nurse investigators to address the complex problems related to improving patient care. These initiatives have been successful in encouraging more nurses to choose both predoctoral and postdoctoral training. There is a strategic plan for systematically increasing the number of supported trainees and

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fellows to 320 per year. This number is based on the recommendation of the Institute of Medicine 1985 report on Personnel Needs and Training for Biomedical and Behavioral Research. By FY 1990, the number of supported trainees/fellows had increased from 165 in FY 1986 to 257. However, in 1992, in order to increase funds for research project grants, it is not possible to continue to increase the number of individuals supported for research training.

QUESTIONS SUBMITTTED BY SENATOR ARLEN SPECTER

PREVENTION OF LOW BIRTHWEIGHT

Question. Dr. Hinshaw, I understand that one of the priority areas of study established by the Center is the Prevention and Care of Low Birthweight Babies. You discussed this briefly in your testimony. Dr. Hinshaw, this is an extremely serious problem in this country, would you elaborate further on the Center's research agenda in this area, particularly as it concerns efforts to prevent low birthweight babies?

Answer. The NCNR, in collaboration with the National Institute of Child Health and Human Development (NICHD), is encouraging interdisciplinary teams of basic and clinical scientists to address issues related to caring for very low birthweight babies in intensive care units as well as issues related to the prevention of LBW.

Neonatal intensive care units are an important factor in the survival of LBW infants, especially those weighing less than 2,500 grams. A major problem in neonatal clinical practice is the balance between prompt implementation of new technologies, procedures, and treatments and the demonstration of their safety and efficacy. Studies that focus on problems of infant feeding, respiratory support, body temperature and skin care are needed to advance our understanding of the underlying explanatory biobehavioral mechanisms that determine the health of these infants.

Another initiative is encouraging the study of factors which may be effective in preventing preterm delivery and intrauterine growth retardation, particularly those related to nursing practice. Risk factors associated with LBW include maternal age, poverty, race, low educational levels, multiparity, and inadequate prenatal care. Maternal behaviors such as substance abuse, smoking, alcohol consumption, and excessive exercise or standing increase the incidence of premature labor. Innovative studies related to maternal behavior and life style, environmental risks, and the biobehavioral interface are needed.

NURSING SHORTAGE

Question. Dr. Hinshaw, maintaining an adequate pool of well trained nurses is essential to the delivery of efficient and affordable health care. This Committee has particularly been concerned and has provided strong support for nurse training programs over the past several years. Has progress been made in addressing the shortfall of trained nurses?