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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. 8. 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
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.
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. We 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.