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community housing options, and income security programs for the oldest old. Continued research in this important area should unlock the mystery of recent improvements in life expectancy among the elderly and should improve the accuracy of population projections for the oldest old.
Question. The Committee strongly encouraged the NIA to undertake a demographic research program on the oldest old with special emphasis on a study that focuses on those who are relatively robust or capable of regaining function. What progress have you made on this study? Will any additional resources be needed? Will the study include adequate numbers of the black oldest old?
Answer. A study on the robust population age 85 and older, those capable of regaining physical functioning, may lead to insights into ways to modify the course of disability. As part of the enhancement of the demographic research program such a study is under discussion, although the age limit may be dropped from age 85 to age 75 to include a comparison group for the 85 plus group and also to follow these people through subsequent interviews, if possible.
During the planning stages for this study, a number of opportunities have surfaced which would allow NIA to take advantage of other planned research activities to minimize the cost of this study while enhancing data collection procedures. For example, the National Institute on Aging/Health and Retirement Survey Monitoring Committee Meeting of March 5, 1991 included a discussion of the opportunity to save a substantial amount of money by taking advantage of the Health and Retirement Study (HRS) sampling frame. In order to locate the 8,000 households containing a person between the ages of 51-61 for the HRS, many households will be screened containing persons age 75 and older. The persons age 75 and older will be inappropriate for the HRS but appropriate for a study of the robust oldest old.
The National Center for Health Statistics (NCHS) is currently planning a second cohort of the Longitudinal Survey on Aging (LSOA), and it may be possible to have the data collection for both the study of the robust oldest old and the new LSOA cohort conducted by the same organization. Discussions along these lines will continue between NIA and NCHS.
NIA has allocated funds to begin designing the survey; plans are to ensure inclusion of adequate numbers of underrepresented groups, The cost of the study is dependent upon the actual design of the survey. It is certain that we will need to "over-sample" households to ensure inclusion of sufficient numbers of underrepresented groups, such as oldest old Black males.
QUESTIONS SUBMITTTED BY SENATOR DALE BUMPERS
Question. As you are well aware, the family is the major source of support for older Americans. However, current trends in fertility, divorce and women working outside the home are
affecting the family's ability to sustain this support. NIA funding any research on families, intergenerational relationships, and women's roles?
Answer. For people of all ages, few relationships are as important to individuals as the social, emotional, and economic ties linking family members. Research supported by the NIA can be illustrated by four types of studies, as follows:
o Family Life, Well-Being, and Abuse. Despite all the changes often described as "weakening" the family, many studies demonstrate that kinship solidarity has certainly not altogether disappeared. For example, sibling relationships are important ties that extend into older ages and are an alternate source of assistance for childless older people. On the whole, older people are themselves active participants in the kinship network: late into old age, parents contribute money and resources to adult children. Even divorce has some positive consequences. Where couples in the middle generation are divorced, the relationship between maternal grandparents and grandchildren becomes deeper and stronger, although relationships on the paternal side become weaker. At the same time, research also examines family conflict, since mistreatment and exploitation of one generation by another are growing national and research concerns. One of the few NIAsupported studies of elder abuse prevalence estimated an overall maltreatment rate of 32 elderly persons per 1000. Family violence is a neglected research area in aging, and NIA has developed new initiatives to increase studies of the causes and possible treatment of elder abuse.
o Family Caregiving and Intergenerational Exchange. Families are the preferred source of long term care for frail elders. For program planning purposes at the community level it is important to better understand caregiving roles of different family members. -1.e., daughters, sons, etc. Women, often adult daughters, are the primary family caregivers. Studies of the burdens of family caregiving include development of interventions to alleviate caregiver strain. Given suitable community supports, family members can find their responsibilities rewarding. For example, a majority of adult daughters caring for their widowed mothers reported that the caregiving relationship positively affected the mother-daughter bonds. To explore societal-level intergenerational exchanges, the NIA continues to support several studies under the 1989 RFA on Intergenerational Relationships which use national data to examine such exchanges. Commanding additional attention is the question whether interventions to increase provision of community services will reduce the help currently provided by family caregivers, since possible "substitution" is a major consideration in forming public policy.
o Changing Women's Roles. As women have been entering the labor force in dramatically increasing numbers, they are contributing to the economic security of family members of all ages.
However, this trend raises critical questions as to their availability--and indeed their own stamina--as family caretakers. Some women in the middle generation, if employed, are vulnerable to the strains of balancing competing responsibilities for child care, career, family life, and care of aging parents. One recent longitudinal study has shown a certain longevity advantage for
working women compared with those not working outside the home; but serious issues of the health consequences of combining paid work and family care remain to be studied. Several studies have postulated emergent changes in the traditional patterns of caretaking, so that men might share more equally with women in personal care for older family members. However, most findings confirm that men remain more limited in their caretaking responsibilities than women. As these changes continue, they require regular tracking through research that can specify the implications for the support needs of older Americans.
o Family Life and Minority Aging. NIA-supported research on African Americans suggests that the extended family (sisters, aunts, cousins) and non-relatives provide considerable support for older Blacks. Older Black women contribute significantly to their families, and to the extended community, by caring for children in the absence or worktime of the mothers, many of whom are single. The families of minority older people are also changing. An NIAsupported study showed that three-generational relationships were complicated by language differences because English-speaking grandchildren had difficulty communicating with their Spanishspeaking grandparents. Among Asian elders, clear differences have been found between Koreans and Chinese in preferences and expectations for family care. Research on such differences is critical for optimal program planning at the community level.
o Future Directions. The research currently supported points to significant unanswered questions about family life for older people. Issues of generational equity necessitate increased national-level studies, while concerns for continued family solidarity and conflict are important for individual well-being. The rapid changes in women's roles as well as family structure are related to ability to plan for the long term care of frail elders.
HEALTH, BEHAVIOR, AND INDEPENDENCE
Question. The Senate has directed NIH to expand its research on health and behavior. This committee directed NIA to expand its research to "1) gain a better understanding of how older Americans and their families cope with life stress, chronic conditions and disabilities; 2) study how social circumstances, ethnicity, gender and age alter health risks; and 3) develop and test interventions that improve the health and independent functioning of older adults." How is NIA responding to this directive, and are there any barriers to implementing an expanded program of research on these important issues?
Answer. Medical care alone will not eliminate the devastating impact of chronic illness and disabilities faced by many older people and their families. Behavioral and social factors play a major role in health and well-being. NIA has developed a focused research agenda to understand the interrelationships of health and behavior in the middle and later years. In addition, although much dependence is related to chronic diseases which are not yet completely curable or preventible, research has identified many possibilities for improving the independence of older persons.
o Coping with Chronic Conditions and Disabilities. NIA research includes studies of how factors such as health practices, sense of personal control, and coping styles mediate the consequences of general dependency as well as specific conditions (e.g. cancer, arthritis, and Alzheimer's disease). Also investigated are the interrelationship of individual characteristics with social circumstances including economic status, social support, and living environments. Because families are the primary caregivers for older people, special attention is given to research on family and intergenerational relationships.
o Social Influences on Health Risk. NIA places specific emphasis on studies of ethnic and cultural variations in health behaviors. Also highlighted are other populations such as women, the oldest old, and rural older people which are believed to have unique health needs and behavior patterns. For example, one NIA study identified differences among Black, Hispanic, and nonminority older people in their use of health care services. Another study is examining social aspects of the menopause and consequences for health care use. Three specialized centers on rural aging research have been established.
o Psychosocial Interventions. Social and behavioral research points to interventions that can improve the health and functioning of older individuals, Currently supported intervention studies include behavioral treatments for urinary incontinence, clinical trials for injury prevention, innovations in health care delivery such as special care units for Alzheimer's disease and related dementias, psychosocial approaches to relieve the burdens of caregiving, and cognitive training programs to enable older people to maintain their driving skills.
o Future Directions on Health and Behavior. Specific NIA initiatives have been developed to address the critical need for intensified research efforts. These include plans for stimulating additional research on appropriate self-care behaviors for older people, health behavior research on cancer, injuries, and AIDS prevention, family relationships including elder abuse, aging and new models of health care, gender differences in health and longevity, minority aging and family life, human factors research, and changing ageist attitudes and behaviors.
o Claude D. Pepper Older Americans Independence Centers. To address the problems of physical frailty, in 1990 Congress authorized establishment of at least ten Centers, in which testing interventions to maintain or increase independence of older persons is a central, required component. Other key aspects of the Centers include career development of new investigators to test further interventions to increase independence, and information dissemination to translate research results of the Centers into health care practice. Four awards are expected to be made in FY 1991; at least ten applications are expected to be of very high quality.
o Interventions to Reduce Physical Frailty. As noted in NIA's first annual report to the Committee on this topic, physical frailty (impairments in physical abilities needed to live independently) is a major cause of long-term care needs, afflicting over 3.25 million older Americans. Increasingly, we
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
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