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

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