EL

OUR FUTURE SELVES

{
U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service National Institutes of Health ~~

 
 
 

J ous FUTURE SELVES |

A RESEARCH PLAN

TOWARD UNDERSTANDING AGING

 

of the

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

Prepared by the

National Institute on Aging
4

With the Advice of the

National Advisory Council on Aging

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
Public Health Service
National Institutes of Health

DHEW Publication No. 77-1096 U.S. DEPOSITORY

MAY 20 1977
 
 

| | cir neces

   
HQ
1064
US
PREFACE N28
PUBL

Our social, economic, health, research, and other vital
institutions and arrangements were not prepared for the
"demographic revolution'--the dramatically rising numbers
of people, and especially older people, that came with the
twentieth century. Thus, the human triumph marked by:
increasing life expectancy contained potential and actual
tragedies for all too many older people and their families.
And, unless these same institutions and arrangements are
not perfected in the next decades, the possibilities for
personal tragedies—-and social disturbances—-will expand
as the absolute numbers and relative proportions of the
population over 65 attain new heights at approximately
2020 A.D.

However, what if our nation-—and collectively other natiouns--
take the demographic achievement still further and extend

the vigor and productivity of older people? What if the
nature and the duration of the dependency and frailty of

old age are altered and decreased through fundamental bio-
medical and behavioral research? Then we will be confronted,
not with older people as we presently know them and old age
as we presently know it, but an entirely new situation,

some evidences of which we are beginning to see in the active
and activistic, lively and resourceful older people of today.
From that angle, research is concerned with what old age will
become as we eliminate disease, disability, and social
adversity. Of course, research alone cannot accomplish the
objective of a healthier and stronger older population, but
without the fruits of research it is not likely that our
social and economic institutions and arrangements can go far
beyond palliation.

 

The quality, not alone the quantity, of life should be the
quintessential goal of research as well as other human
efforts——lest our future selves will be in jeopardy.

1799
Through the accumulated knowledge and the generosity in time
and effort of the National Advisory Council of the National
Institute on Aging, the National Institute on Aging staff,
and the broad community of gerontologists, we have the begin-
ning formulations of a significant new research effort in
America: the accompanying Research Plan. It is a reasonable
and reasoned promise of a major endeavor to comprehend the
nature of aging and its associated ills with the ultimate
aspiration of a more decent and dignified old age.

Robert N. Butler, M.D.
Director
National Institute on Aging

ii
II.

111.

Iv.

VI.

TABLE OF CONTENTS

Introduction. « « + « 5 « « = # ou © # » #

The Need for Research. . .

Research Priorities . . . . . . . .

Research Resources. . . .

Brief Legislative History of
Research in Aging Within HEW. .

Research Coordination and Resource Needs.

Summary Statement of
Selected Research Opportunities . . .

13

31

40

54

58
oe en
Chapter 1

INTRODUCTTION

 

“The Secretary . . . shall . . . develop
a plan for a research program on aging
designed to coordinate and promote
research into the biological, medical,
psychological, social, educational,

and economic aspects of aging." 1/

This Nation's elderly hold up a distorted mirror to our society.
The distortion is imposed by two elements: the vital supports
which many of the elderly lose merely by the fact of naving be-
come aged; and our ignorance of what aging is--an ignorance
made the more profound by our societal resistance to acknow-
ledging the fact of aging and preparing adequately for it.

UNFULFILLED EXPECTATIONS

The normal supports available to much of our population but
frequently unavailable to the aged include:

o jobs and basic economic security
o quality health care (physical and mental)
o transportation

o a full range of legal and other professional
services

o decent housing arrangements
o protection from crime

Such supports are by and large not available to the aged.
Despite inadequate income and savings, many have no job

or at best only part-time work, and no ready surrogate

for the loss of self-worth and esteem that accompanies an
end to employment. The aged learn that the medical system
that fits their needs in middle age is now out of phase, not
structured--in manpower, institutional resources, payment

 

1/ The Research on Aging Act of 1974, P.L. 93-296
mechanisms, or motivation--to deal with the chronic impair-
ments and long-term illnesses that may now afflict them.

There is not sufficient psychiatric help or understanding to
aid in coping with the wrenching changes and strains of old
age--bereavement, loneliness, financial and social insecuri-
ties. Many aged persons find their financial resources mea-
ger and dwindling: most elderly couples and individuals have
less than $5,000 in assets and many less than $1,000. The
aged often learn that they can no longer easily get where they
need to go, that their housing is inadequate, their pensions
too little.

The effect on many of the elderly is to blunt the inherent
values and joys of old age--a time to reflect on one's life,
synthesizing experiences, passing on learned wisdom and phil-
osophies to others, preparing for and understanding the com-—
ing of death. Rather than old age being a time to savor the
final stages of human development, it often becomes a struggle
to survive in what is perceived by many aged as an increasing-
ly alien society. Perhaps most tragically, old age is lacking
in a life-long sense of accomplishment and self-worth.

THE NATURE OF AGING

We do not know what aging is. Consequently, we cannot crisply
separate the changes--social, behavioral, biological--intrin-
sic to aging, from those changes imposed by medical history,
cultural and ethnic settings, the manner of a person's life,
and other extermals. Not knowing what aging really is or
means, we generally rely on an arbitrary chronological divi-
sion between middle-age and old age, usually set at 60 years.
Commonly, a person passing this limit is conditioned to a uni-
form set of beliefs about aging and the aged: intellectual
decline slipping into senility; inevitably, entry into an
institution; and increased vulnerability to certain diseases
and disorders--such as diabetes, atherosclerosis, arthritis,
blindness, and dementia.

But these are pieces of a myth. Reaction times do slow with
age, but most of the aged fully retain until they are very old,
and often until their death, their ability to reason, their
memory, their wit. The elderly sometimes seem lonely and with-
drawn, but that may be the result of society withdrawing from
them. The elderly commonly have decreased glucose tolerance,
decreased creatinine clearances, and higher blood pressures,
but not all are diabetic, have kidney disease, or are hyper-
tensive. We associate the elderly--particularly the very
old--with institutions, but in fact, at any moment in time,
only about 6 percent are there; the other 94 percent usually
prefer to stay out, and generally can care quite well for
themselves despite the fact that many suffer some chronic
illness or impairment.

RESEARCH ON AGING

The implication for aging research that emerges from the pre-
ceding considerations is that to mount effective programs we
must understand which changes with age are due to the normal
process of aging itself and which are due to an individual's
heredity, cultural setting, life style and so on. Therefore,
in this research plan--most particularly, in the chapter on
research priorities—-two premises underlie the recommendations
for research to be conducted by biomedical, behavioral, and
social scientists:

o effective programs for the aged--whether
medical or social, treatment or prevention--
must be based on knowing which changes in the
aged are intrinsic to the aging process and
which are not

o if we are able to prevent or lessen the impact
of non-intrinsic factors in the decline of the
aged, then we are left with a unique and more
satisfying concept of what aging is or should
be--a natural stage in human development
leading to a gradual and peaceful end

Basic studies on aging--biomedical, behavioral, and social
--converge on the issue of designing services and delivering
them: applying what we know so as to enable the aged to enjoy
to the fullest a useful and active life span. Here, again,
two interrelated premises apply:

o existing services for the elderly are flawed,
be they health-care delivery and compensation
systems, community services inaccessible to
the aged, or inadequate and sometimes unsympa-
thetic mental health services

o these shortcomings in existing services and
delivery systems will become even more apparent
as the average age of our population continues
to rise, and as our population over 65 continues
to increase in the coming decades
THE RESEARCH PLAN

Priorities for the three major areas of aging research--biomed-
ical, behavioral and social science, and human services and
their delivery--are described in Chapter III of this research
plan for DHEW. Chapter IV outlines the required resources to
address these priorities including trained research manpower,
experimental resources such as human and animal populations,
and access to validated data.

Demographic information that outlines the major issues affect-
ing aging and the problems of the aged is given in Chapter II,
while Chapter V gives a brief legislative history of research
on aging within the DHEW. The sixth and final chapter gives
very brief, and at this initial phase necessarily general,
recommendations on future budget needs and means to approach a
coordinated program among various DHEW units on aging and the
problems of the aged.

THE NATIONAL ADVISORY COUNCIL ON AGING

The National Advisory Council on Aging of the National Insti-
tute on Aging was identified legislatively as the primary
source of advice to the Secretary, DHEW, in developing this
plan. And indeed the Council has done just that, displaying

in the process remarkable enthusiasm, diligence, and generosity
of time. The contents of Chapters III and IV, Research Priori-
ties and Research Resources, respectively, are based directly
on materials prepared and advice given by the National Advisory
Council on Aging. Those materials--separate and detailed re-
ports on the state of science and research priorities in the
biomedical sciences, the behavioral and social sciences, and
the developing science of human services and delivery systems--
will be made available in the near future as companion volumes
to the Research Plan.
Chapter II

THE NEED FOR RESEARCH

 

"The Congress finds and declares that . . . the
study of the aging process, the one biological
condition common to all, has not received research
support commensurate with its effects on the lives
of every individual;" 1/

Long life expectancy is a decidedly modern achievement. At

the turn of this century, four of every hundred persons

living in the United States were age 65 or more. Now, only
seventy-six years later, the proportion has more than

doubled, and it is more than 10 of every hundred (Figure 1).
Although this proportion is not expected to rise a great deal
more in the next few decades, the absolute numbers of the aged
will grow rapidly, and the projection is for about 30 million
older persons by the year 2000. These changes in the age com-
position of our population lend increasing urgency to the need
for reply to such critical questions as: How does our society
meet the needs of older people? And, how does their increasing
presence affect other groups in the society?

Nations prize longevity and regard it as an outstanding accom-
plishment when the majority of their citizens live to old age.
Average life expectancy, or average age at death, may be re-
garded as one of the most important indices of social health
and overall quality of life within a society. The problem
this nation faces now is the lag that occurs in adapting its
social institutions to the needs of older people at the same
time that the needs of younger people are being met. In
short, problems arise when a nation like the United States has
not been prepared for the ''sudden' appearance of large numbers
of older people.

The aging society has brought with it a certain proportion of
older persons who suffer from poverty, preventable illness,
and social isolation. These persons, who can be termed the
needy aged, create acute problems in the fields of social and
health care. But broader issues stem from the needs of all
individuals to adjust to the new rhythms of life that come

1/ The Kesearch on Aging Act of 1974, P.L. 93-296
PERCENT

The Percentage of Population Aged 65 and
OlderHas Increased

14

 

13 = SOURCE: National Center
for Health Statistics

 

 

 

0 | | l | | | | | |
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

 

YEAR

Figure 1.
with increased longevity: to new social phenomena such as
multigenerational families, retirement, increased leisure,
changing health status, and to the new opportunities and new
problems of adaptation that accompany a long life. And for
the society at large innumerable policy questions arise as the
whole social fabric accommodates itself to the new phenomenon
of the changing age distribution.

In over-simplified terms the American society in the 1970's
faces two different sets of issues. On the one hand, there
are increasing numbers of the '"young-old,'" persons in their
60's and early 70's, who are relatively healthy and vigorous,
a large number of whom are retired, who seek for meaningful
ways to use their time, either in self-fulfillment or in com-
munity participation, and who represent a great resource of
talent for society. On the other hand, there is an even more
dramatic increase in the proportion of the elderly population
which might be termed the "old-old." This comprises persons
in their mid-70's, 80's and 90's, an increasing minority of
whom remain vigorous and active, but a majority of whom need
a wide range of supportive and restorative health services
and social services (Figure 2).

For historical reasons, the old-old of the 1970's represent a
disproportionately disadvantaged group. Many were immigrants
who came to this country with little formal education; many
worked most of their lives at low-skill occupations; many lost
their occupational moorings during the Great Depression and
did not recoup in the period of prosperity ushered in by World
War II, nor did they build up sizable equities under the
Social Security program as it developed during the 1940's and
1950's.

In succeeding decades, more and more older people will have
been native-born, will have grown up in urban areas, will

have had high school and college educations, will hopefully
have been spared from widespread economic catastrophe, and
will benefit from pension programs, social security, and gov-
ernment service programs of all types. Thus the persons grow-
ing old in the future will probably have very different char-
acteristics from those who are presently old.

These different characteristics will in turn lead to vastly
differing expectations, and as a consequence there is an
urgent need to plan not only for those who are the present
aged, but also for the future aged. The dimensions of the
problem may be described in the following demographic terms:
between 1900 and 1970, there has been an
enormous gain in life expectancy, a gain of

some 20 years. However, the gain is due mainly
to lower infant mortalities, rather than better
health care for adults; thus, taking 1950 rather
than 1900 for the base year, life expectancy at
birth increased by only one and three years for
men and women, respectively; and for men aged

65 in 1950, life expectancy actually decreased.

women live longer on the average than men; and

the increase in life expectancy at birth since

1900 has been greater for women (25 years) than

for men (20 years). For non-whites, these increases
have been even more striking (35 years for women

vs. 29 years for men).

present trends suggest that, barring major medical
breakthroughs which might dramatically reduce
death rates, further gains in life expectancy at
birth will be relatively small. By the year 2000,
there may be an increase in men of 1 to 2 years,
and in women of perhaps 5 to 6 years.

the numbers of older persons will increase drama-
tically in the next few decades, even without any
new biological discoveries and without any sudden
jump in the length of the human life span. At
present there are over 22 million persons aged 65+
in the United States. According to current pro-
jections the total will be over 30 million by the
year 2000. Compared to their present 10.5 percent
of the total population, they will then constitute
about 11.5 percent.

while the increase in the aged population between
1970 and 2000 is not expected to be as dramatic
as it was between 1940 and 1970--20 million to

30 million versus 9 million to 20 million--there
will be another surge in the decade after 2000
when the post-war babies reach 65.

the numbers of old-old (75+) will grow at a more
rapid rate than the young-old; and the ratio of
women to men will increase even more. Thus, by the
year 2000 the older population will be more heavily
weighted toward the very old (Figure 2), and par-
ticularly toward very old women.
The Proportion of the Very Old Among the Elderly Is Increasing

85+ pr / 057 Yb 757

7584 | (25 [27] |
“, =

 

 

 

 

 

 

 

 

 

[a8].

 

65-74

 

 

 

 

 

 

 

  

 

 

 

 

 

1900 1950 1975 2000

SOURCE: National Center
Figure 2. for Health Statistics
10

o expenditures for medical care for the elderly more
than tripled between 1966 and 1974 (Figure 3). A
continuation of present population trends leads
inescapably to the prediction of yet further growth
of these costs.

o public funds are by far the most significant source
of support for the nearly $27 billion costs of
hospital care incurred by the elderly (Figure 4).

Given these factors and the projects which derive from them, it is
obvious that the status of our citizens must receive greater scrutiny
now and in the future. Carefully plotted research strategies offer
the greatest promise for providing every citizen an old age which is
as rewarding intellectually, physically, socially, and economically
as our enlightened society can provide.
$7.9 BILLION

 

 

1966

Expenditures for Medical Care for ‘the Elderly
Have More Than Tripled Since 1966

$26.7 BILLION"

7
2)
PHYSICIAN

SERVICES 7
a.

N

ZT

        
    
   
    
 

OTHER
SERVICES

 
   
  
  

EYEGLASSES &
APPLIANCES

remem he

‘NURSING:
Te
CARE.

 
  

1974

Figure 3.

SOURCE: National Center
~ for Health Statistics

TT
Public Funds Pay the Highest Proportion of Hospital
Costs for the Elderly

$12.6 BILLIONS

 

 

 

li: Tl PRIVATE

 

 

   

PUBLIC

 

 

 

  
  
 

$6.3 BILLIONS

7 $4.0 BILLIONS
7 SOURCE: National Center
+ $2.3 BILLIONS for Health Statistics

nnn;

 

 

 

 

 

$1.1 BILLIONS

 

 

 

 

 

 

 

 

 

 

 

 

  

 

 

 

 

 

 

 

 

$.5 BILLIONS
. ay JY rrr
NURSING PHYSICIANS DRUG AND OTHER EYEGLASSES &
HOME SERVICES DRUG SERVICES APPLIANCES
CARE SUNDRIES

 

Figure 4.

21
13

Chapter III

KESEARKCHH PRIOKITTIES

 

"The Congress finds and declares that. . .in
addition to the physical infirmities resulting
from advanced age, the economic, social, and
psychological factors associated with aging
operate to exclude millions of older Americans
from the full life and the place in our society
to which their years of service and experience
entitle them." 1/

The Department of Health, Education, and Welfare, like other
departments of the Government, is concerned with the well-
being of society. Satisfying that concern becomes increasingly
complex. For instance, the maintenance of health and often

the effective treatment of illness requires a wide variety

of social and health-supportive services in addition to medical
skills.

Thus, mental and physical health depends to an increasing extent
upon public programs of sanitation and hygiene; upon social
policies that safeguard the physical environment against pollu-
tion and the depletion of essential resources; upon a variety

of health delivery systems that include an emphasis on
supportive services; upon equitable distribution of goods

and services; and upon development of a human environment that
reduces violent behavior, tensions, anxieties, and other social
and psychological pathologies. Health also depends upon the
willingness and the ability of individuals to care for them-
selves, and to apply the principles of preventive medicine by
emphasizing in their lives those elements that foster health and
the prevention of dependency and disability.

Tne interdependency of biological and social factors in
effective health care is clearly apparent in efforts to
understand and treat the problems of the aged. Appreciation
of the position of the aged in our society and the effects
of an increased proportion of older people on the entire
society, requires emphasis on both biomedical and social
research.

 

1/ The Research on Aging Act of 1974, P.L. 93-296
14

DIVISION OF RESEAKCH PRIOKITIES

The research priorities described in tnis chapter are given
in three categories: the biomedical sciences, the behavioral
and social sciences, and human services and their delivery.
This division 1s somewhat artificial but still necessary.

It is artificial because to divide priorities by areas
belies the truism that the problems of aging and the aged
are immensely complex, not readily divisible, requiring a
nolistic, comprehensive, and systematic approach.

However, the difficulties inherent in research on aging and
the aged also make it clear that a single approach will at
the very least lead to frustrations and disappointments and
at the worst to failures in signiticantly advancing our know-
ledge. What is required is a well-planned and carefully
coordinated application of the pertinent scientific disci-
plines--genetics, biochemistry, epidemiology, demography,
sociology, psychology, anthropology, economics, political
science, and others. With this discipline-oriented approach,
the methods of many sciences can be applied to a common prob-
lem and a cadre of nighly-trained researchers created, having
as its central focus the problems of aging and the aged.

As in other fields of research, when new hypotheses on the
process of aging are presented, the methodology needed to

test them may not be available. Or where there is applicable
methodology, there may be inadequate data. The encouragement
of highly-competent researchers trained in specific disciplines
can stimulate the flow of good ideas and hypotheses, enrich

the methodology, and enlarge the stock of validated data.

An obvious goal of this intensified and concerted research
effort is to foster the health and vigor of a growing segment
of the American population. But what we learn from this effort
will ultimately benefit the entire population. For if we can
identify the factors that so enormously increase the risk of
coronary thrombosis among the aged, we can also identify those
factors that are preventable and then design suitable pro-
grams; if we can find better ways to deliver health care to

the aged, the lessons learned may be applied to the delivery

of effective and economic health care to the society-at-large.
15

BIOMEDICAL RESEARCH

Basic and clinical biomedical research can improve the
quality of life for the aged (e.g., by relieving many of
their painful disabilities), enable more people to fully
realize their natural life span, and guide the creation of
effective health-care services.

To approach these goals, we must be able to distinguish

aging from disease. The elderly ill--and usually their
families and physicians--commonly attribute many of their
symptoms to aging and therefore regard them as immutable when
their illnesses may in fact be treatable. Cancer, stroke,
painful and crippled joints, mental confusion, and heart
disease are not the inevitable tolls of aging; rather, they
are the results of a variety of causes not intrinsically related
to age. Nor are normal physiological changes with age to

be regarded as diagnostic signs of diseases such as
hypertension and diabetes.

But aging is the result of a series of fundamental, if

poorly understood, biological changes, and therefore aging

can affect the course, symptoms, prognosis, and effective-
ness of therapy of diseases and disabilities usual to the
aged. For example, normal changes in the immune system

with age determine a person's resistance to infection. We
must delineate these and other effects of aging on the
characteristics of disease to help guide therapy, assay its
effectiveness, and to evaluate the effects of various diseases
on the process of aging.

To distinguish aging from disease and to examine the effects
of one upon the other, we need a clear description of the
aging process at all levels of life: the genes, their struc-
ture, expression, and regulation; the various constituents
of the cell, such as the mitochondrion and nucleus; the

cell itself; organs and organ systems, such as the respira-
tory, nervous, and cardiovascular systems.

Without knowing what changes occur with age, we cannot find
their causes. Nor can we reliably determine the normal range
of physiological, structural, and other changes with age.
Different systems of the body--endocrine, cardiovascular,
16

gastrointestinal, and so on--age at different rates that
are determined to varying degrees by a person's genetic makeup
and environment. These progressive changes modulate the
characteristics of disabilities, diseases, and infirmities
suffered by the aged, including arteriosclerosis (hard-
ening of the arteries), many of the common forms of cancer,
diabetes mellitus, osteoporosis (loss of bone mass), osteo-
arthritis (chronic degenerative joint diseases), benign
prostatic hypertrophy (enlargement of the prostate gland),
pulmonary emphysema, cataracts, depressive illnesses, and
senile dementia (a form of mental deterioration).

These diseases—-many the province of disease-oriented Insti-
tutes of the NIH--can be extremely powerful probes for under-
standing the aging process, since ''nature nowhere so reveals
her usual workings as when she deviates from her usual paths."
The stance of the researcher on aging is to relate the nature
and course of those diseases to genetically controlled changes
with time in biological structures and functions. What is
ultimately gained is an understanding of the interacting
influences of genetics and enviromment in age-associated
diseases as different as osteoporosis and senile dementia.

Clearly, biomedical research on aging has implications for
virtually all the major ailments of man. By probing possible
relationships between the aging process and the development

of cancers common to the aged, we may better understand the
causes and nature of other cancers; by identifying the factors
leading to coronary thrombosis, we perhaps can design programs
of prevention, not only for the aged, but also for those still
young and in the midst of productive careers.

Biomedical research on aging can be divided into two broad
categories: the mechanisms of aging and the interaction of
aging with external influences. The first covers the gamut
from molecular genetics to clinical aspects of disease in the
elderly, while the second analyzes the influences on aging of
diet and nutrition, drugs and their metabolism, and a variety
of other chemical and physical factors. The approaches used
for both categories range from the very fundamental to the
applied, from the biology of aging cells to longitudinal
studies of aging populations, from basic immunology to analy-
zing the response of the elderly to primary and secondary
infections, from an analysis of cell structures to a study

of the effects of different diets on resistance to diseases.
17

Priorities

Against that background, a number of initial, highly
selected research priorities can be emphasized:

The Cell--Structure, Biochemistry, Genetics, and Physiology

Cellular research related to aging has emphasized the identi-
fication and description of apparent cellular changes with
age. While we now have a large and still growing list of
such changes, we do not know which are related directly to
the aging process and which are not. Fundamental cellular
studies should help distinguish the significant changes and
may answer essential questions, such as

o the effects of experimental and natural changes
on the various constituents of the cell, inclu-
ding their functioning, physiology, and structure

o the causal relationships, if any, between the
decline of the numbers of functional cells and the

decline of the physiological functions of organs
and organ systems

o factors influencing the life span of cells
Normal Physiological Changes With Age

We have little quantitative and reliable information on physio-
logical changes with age, particularly in those organ systems--
cardiovascular, pulmonary, endocrine, and nervous--whose
failures account for a large proportion of the mortalities

and morbidities among the aged. Well conceived and executed
investigations of normal physiological changes with age can

o support the basic objective of aging research
of extending the useful life span

o establish physiological baselines by age to
enable other NIH Institutes more effectively
to probe various disease processes

o assess the value of exercise in slowing the
normal decline of physiological functions.
18

Immunological Changes

 

The immune system is intimately related to the body's adapt-
ation to environmental stress and change. Various normal
immunological functions appear to decline with age.
Associated with these declines--and perhaps causally

related to them—--is the increase with age of the incidence
of immunologically related diseases such as various
auto-immune diseases, cancer, and antigen-antibody

diseases. Studies of the normal range of immune activity
with age may lead to experimental programs on the restoration
or slowing of declining immunological functions. In
addition, answers may be provided to some provocative
questions, including

o what is the normal level of immune function for
an aged person?

o what role does the immune system have in the
aging process?

o why do the elderly respond differently--and often
more poorly--to infections than the young?

Clinical Diagnosis--Definition of Normal Standards by Age

 

Physiological changes with age obviously have an impact on
the diseases of the aged. For example, diseases such as
diabetes mellitus, tuberculosis, and bacterial endocarditis
display different symptoms in the elderly than in the young
or middle-aged; the pain typically associated with some ill-
nesses--coronary thrombosis, intestinal obstructions, and
acute appendicitis--may not be present or as obvious in the
elderly.

Such changes in the presentation of illness, due in part to
normal physiological changes, must be examined collaboratively
by physiologists and clinicians. There is an absence, by and
large, of physiological standards for the elderly. When
measurements have been made, they have typically been made

on men, despite the well-recognized and often major differ-
ences in many physiological functions between men and women.
Consequently, considerably more research emphasis must be
given to establishing normative information regarding aging
women .
19

Interaction of Aging and Disease

 

There is poor understanding of the interactions of the

normal pathological and physiological changes of aging with
various diseases. The result may be, as with maturity-onset
diabetes, an inability to distinguish aging changes

from disease processes. Or our lack of knowledge may

make it difficult to prescribe therapy or to design
preventative programs, as is the case with atherosclerosis, in
which the factors that contribute to its incidence among the
elderly have not been adequately studied.

Organic Brain Disorders

 

Organic brain disorders are due to chemical or physical
changes, and may be reversible or chronic. Although they
occur most frequently among the elderly, efforts to find
causes of organic brain disorders should help victims of
all ages. We must also intensify our efforts to improve
diagnostic tests and therapies, both being now inadequate.

Changes in Nutrient Requirements and Metabolism with Age

 

There is no rational basis for nutritional recommendations

for the elderly, an awkward fact since many public and private
programs center on or include the delivery of nutritional
services to the elderly. Moreover, diet may be a factor in
producing certain diseases such as atherosclerosis, and

in ameliorating others, such as diabetes.

We need fundamental information regarding changes in nutrient
metabolism with age if we are to define the needs of the
elderly, plan effective and economic nutritional programs,
and use diet as one element in blunting the impact of physio-
logical decline.

BEHAVIORAL AND SOCIAL SCIENCE RESEARCH

For the next several decades, the United States-—and other
developed countries--will have an increasing population of the
elderly, one in which females are predominant. The effective-
ness of policies designed in response to these population
changes will depend on how well we understand the aged, indi-
vidually and as groups. Partial knowledge and false assump-
tions may lead to policies and legislation with unexpected,
perhaps disappointing results.
20

The elderly are a diverse group, with individual differences
often more telling than similarities. But to aid analysis,
the aged population can be divided into the old and

very old. The old are those as young as sixty, probably
retired, usually healthy and vigorous, often anxious

to apply their talents, knowledge, and time meaningfully,
and therefore constituting a valuable if often unused
resource. The very old are 75 years of age or older.

Many in this group are vigorous and self-sufficient; others
can manage their lives if given some support by health and
social services; while a small number--but one that grows with
age—--need sustained support.

Even allowing for the division of the aged population into

two groups, there is still the fact that the aged are a highly
diverse population, not readily quantified or labeled. Also,
there are not adequate theories to help us to understand the
behavior of aging persons or groups. That is true whether

the pertinent discipline is psychology, sociology, anthro-
pology, economics, or political science.

However, the increased level of research on the aged begin-
ning in the 1950s has led to several insights on which effect-
ive research programs can be based.

One such insight is that, in contrast to prevailing myth,

most of the "normal" aged--70-75 percent of those over 65 years
of age--are intellectually and socially able, productive

(given the opportunity), mentally vigorous, interested in

their surroundings, eager to participate in the social life

of family, kin, and community. Where there are decrements

and apparent declines, the cause is not necessarily the bio-
logical process of aging, but other, often controllable
impositions only partially related to age--disease, social
isolation, poor diet, limited education, economic plight. The
inability of some aged persons to cope intellectually and socially
is usually due to stresses associated with aging than caused by
it. This view, that at least some declines are not inexorably
bound to the normal pattern of human development, forces the
conclusion that it is possible to prevent or treat many of

the intellectual, social, and emotional problems of a signi-
ficant proportion of the aged population. Moreover, it
emphasizes the ability of many of the aged, given the oppor-
tunity, to lead independent, self-sustaining, satisfying

lives.
21

That a substantial majority of the aged are indeed intellect-
ually and socially competent is supported by the demonstrable
fact that integration of the older person in the society is
the norm rather than the exception in every society that has
been carefully studied, including the United States. Insti-
tutionalization is limited to a small fraction of the aged.

A significant number of the aged able to participate socially
is excluded for a variety of reasons-—apparent disability or
illness, or a latent prejudice against any aged person.

How an aged person responds to stress--illness, deep grief,
financial strains--is largely a function of the life lived

and the experiences had. It has little to do with age or

aging per se. Rather, the capacity to cope is dependent
primarily on education, work patterns, family--all the ele-
ments that structured one's life, modulated it, and gave it
meaning. And, a person's character--his or her individuality--
remains intact until near if not to the very end of life.

The fact that individuality is maintained into very old age
requires that programs for the elderly, to be effective,
must provide a wide range of options--in education, in work
and leisure, in housing and living arrangements, in social
and health services. Pervading these policy considerations
is the fact, established by social research, that all modern
developed societies have the wherewithal, even with shifting
proportions of workers and retirees, to maintain adequate
income for the elderly and finance essential services for
those who need them. The willingness to do these things is
another matter, and is dependent on political judgments,
cultural values, national priorities, and principles of
equity.

Finally, an issue posing very difficult questions is the
ability of modern medical technology to modulate if not con-
trol the process of dying. Rising concerns, generated by
humanistic and personal insights, have prompted clinical,
educational, and other research programs to help seriously
impaired or dying individuals and their families. There

are also emergent ethical and scientific issues concerned
with the definition of death and the use of technology

to prolong life.

Priorities

Against that background, a number of research priorities can
be recommended to build on what we know and to aid in the
making of effective policies for a rapidly growing segment
of our population:
22

Reduction and Prevention of Dependency

Dependency--social, economic, and physical--is a particularly
serious problem for the very old, and for the young who care
for them. There are several issues that should be studied as
part of efforts to blunt the impact of such dependencies or
to prevent them altogether

o the process by which an impairment becomes a
disability, including the pertinent social,
psychological, and biomedical factors

o the physiological and psychological variables
related to changes in cognitive functioning in
the aged; i.e., memory, learning, intelligence,
and perception

o distinction of age-caused from age-associated
decrements, and identification of those that can
be prevented, treated, or ameliorated

Given the fundamental mental and physical vigor of the aged,
research on dependency leading to effective programs can give
the elderly fruitful and satisfying lives.

Income Maintenance

As the proportion of retired persons in our population in-
creases, so will the absolute costs of income maintenance pro-
grams. How will these programs be paid for? Answers may be
obtained by expanding the use of demographic projections and
models—-the first to estimate the probable costs of income
maintenance programs, and the implications for corporate and
personal income taxes; the second to simulate the economic

and social effects of alternative ways to provide income and
service to the elderly.

Age Discrimination in Employment: The Retirement Process

The rising number of elderly people, the increased financial
burdens of support programs, and the evidence that chrono-
logical age itself usually has little bearing on social and
intellectual competence are several of the elements forcing

an examination of why people retire, particularly of the
elements--social, financial, employment--that enter into indi-
vidual retirement decisions. The ultimate effects of retire-
ment pressures on the larger society should continue to be
examined. In addition, we should
23

o establish functional rather than chronological
criteria of social and intellectual competence

o seek mechanisms--such as demonstration programs-—-
to enable people to be economically productive
beyond the usual retirement ages

o examine the attitudes of both young and old
toward work and leisure

Life Experiences and the Aged Personality

We need precise information on the effects of life experiences
on the elderly. For example, does the aging cohort (age
cluster or group) that lived through the depression display a
different social and behavioral pattern than a cohort that did
not? How are different work histories reflected in financial
security (or lack of it) in retirement? What are the effects
of changing patterns of work and leisure on the lives of diff-
erent cohorts? Subtle influences of experiences as a child
and young adult should be examined, including

o the management of crises
o different social roles in family, work, and community
0 negative stereotypes of the aged
Social Competence and Social Integration
An examination is needed of the factors—--social, cultural, and
environmental--that make for social competence and personal
satisfaction in late life, irrespective of the level of social
integration. Specific elements that should be examined include
o the different problems of men and women in main-
taining social competence and, where desired,
achieving social integration

o racial, ethnic, and social factors

The Aged and Their Families

 

Family and kin provide important social and sometimes economic
support for many of the elderly. What is the nature of the
relationship of the elderly with their families? How do diff-
erent relationships--perhaps determined by different ethnic
24

and cultural values--affect dependency reduction and the
maintenance of social competence? Are the changing roles of
women—--more working-—affecting the abilities of families to
care for their aged? If so, what are these effects and

what do they portend? How are changing family structures--
for example, single-parent families--altering the relation-
ships between the elderly and their families and kin? These
and similar issues must be addressed as part of an effort to
develop policies that emphasize the family as one crucial
supportive resource.

Mortality Rates: Men vs. Women

 

On the average, women live eight years longer than men; and
in 1974 there were 143 older women per 100 men, with the gap
widening. Genetic predisposition, hormonal differences, and
stress are among the explanations offered. More intensive
research is needed to specifically identify the elements that
account for the higher morbidities ‘and mortalities of men.

Social Experiments

The Medicare and Medicaid programs are natural social experi-
ments, since they can be used to examine the effects of
certain types of payment mechanisms on the lives of older
persons, their families and communities, and various parts

of different health-care systems.

X

There should also be limited, small-scale social experiments
on

o flexible or ''phased" retirements

o the impact on older persons of new educational
opportunities that provide not only preparation
for second careers and meaningful leisure, but
also for self-care in old age

o alternative forms of social and health service systems

o alternative physical and social environments,
including housing and long-term care facilities

Psychological and Psychiatric Interventions

 

The maintenance of intellectual functioning among the aged and
prevention of so-called organic brain syndromes and senile
dementias are obvious and critical importance. Well-planned
25

programs of research should stimulate the development of a
clinical psychology and psychiatry attuned to the mental health
problems of the aged.

Government Policies and the Aged

 

The effects of various governmental policies upon the current
and future aged should be examined. What are the effects of
manpower and training programs on employment patterns of the
aged? How do macro-economic policies used to stimulate the
general economy or restrain inflation affect retirees? What
are the consequences for older persons, their families, and
communities of governmental policies on housing, transporta-
tion, health care, and pensions? Are there differences in the
respective effects of such policies on the rural and the urban
elderly?

As the population of older persons enlarges and as the
characteristics of successive cohorts (clusters or groups)
diverge, such studies will be particularly important to city
and regional planners for the coming decades.

RESEARCH ON HUMAN SERVICES AND DELIVERY SYSTEMS

Older persons must have an effective network of facilities,
programs and services to survive short-term crises and meet
long-term needs. Without these supports many lose their capacity
to live independently or semi-independently in their own homes

or communities.

Services for people in the U.S. are provided by a pluralistic
system of governmental (federal, state and municipal), private
non-profit (voluntary) and commercial agencies. But many of
these agencies have not developed programs that meet the special
needs of the aged. For example, the elderly are commonly not
provided preventative medical services--such as early diagnosis
and treatment--that can forestall new problems.

Services have frequently been separately developed or legis-
lated with no planned relationship of one system or set of
resources to another; with conflicting legislative language,
regulations, and funding policies and practices; ambiguous
program objectives; and incongruence between agency or program
goals and needs of older persons.
26

Given the varied and changing needs of older persons, programs
of health and social care to be effective must be comprehen-—
sive--ranging from provision of simple information to direct
services needed to maintain physical and mental functioning.

The design and the evaluation of effective, truly comprehen-
sive programs must be based on systematic, well-planned research
and analysis.

Research has been or is being done in several service areas
of particular pertinence to the elderly--physical, mental and
dental nealth; nutrition and food services; physical living
environments; employment and other economic supports; the
commercial marketplace; transportation; communication; social
services; legal and physical protection; education; civic
participation; leisure and recreation; and spiritual well-
being.

These studies have led to a number of findings that can be
usefully addressed to improve the effectiveness and range of
services and their delivery to the aged:

Medical Care

Medical knowledge and techniques are available to ameliorate
many of the illnesses of late life. But existing health-

care systems are organized primarily to deal with acute,
episodic illnesses in hospital settings. Institutional
health-care systems are, by and large, not linked to com-
munity-pased systems for primary, preventive, rehabili-

tative or supportive care, although such arrangements are
particularly suited to the need for the long-term care of many
older citizens. Compounding the lack of adequate facilities for
the care of the aged is the fact that medical education does not
provide an adequate basis for modern geriatric care.

Home Care

while older persons have high rates of chronic illness and
disability, they continue to function in the community when
services are available. But a study in 1972 found that

54 percent of all American communities, including 99 with
populations of more that 50,000, had no home health agency
whatsoever. And less than 1 percent of Medicare expenditure
went to home health services in 1971. Yet, home care may

save health dollars, and in many cases is the most appropriate
option for proper care of the older person.

 

 
27

Mental Health Care

Studies of mental health in later life indicate that approxi-
mately 15 percent of the population 65 and older are in need
of treatment or intervention to maintain their mental health.
For each 5 years beyond 65 the total proportion of persons
moderately or severely mentally ill increases, from about

10 percent at age 65 to approximately 30 percent at age 80.
Those elderly thus afflicted are responsive to treatment if
or when appropriate treatment is developed and provided.

Pertinent research questions are: What kind of a delivery
system should be developed to meet the mental health problems
of the elderly? Should mental health services be delivered
separately from other health care and social service systems?
Should a new structure such as "health maintenance organiza-
tions for older persons'" be created that integrates physical
and mental health, social and other services?

Nutrition Services

Food consumption studies confirm that the diets of older per-
sons are often below standard both in quantity and quality.
While poorly nourished people are at greater health risk, and
nutrition is related to certain diseases which are reversible,
the number of nutrition programs for older persons is very
limited. Demonstration models of nutrition services for the
elderly have been largely descriptive in nature, testing
feasibility and determining cost. There is also a need to
study the impact on the client and community, to identify
nutritionally vulnerable groups, to test ways to incorporate
nutrition counseling into primary health care, and, most funda-
mentally, to determine the nutritional needs of older persons.

Housing Services

Specially-built housing and age-oriented environments often
benefit the elderly. Improvement of present housing is even
more important than specially-built housing, since 70 percent
of the housing occupied by the elderly is also owned by them.
Research on specific housing alternatives and service pack-
ages, and cost estimates for those alternatives and service
packages, should quickly yield benefits.
28

Institutional Care

Where the appropriate option is institutional care, research
is nonetheless needed to understand and cope more effectively
with the impact of institutionalization. Studies are needed
to assess the quality of institutional care.

An estimated 2.4 million persons aged 65 and older do not need
institutionalization, but do need appropriate shelter and ser-
vices to remain in the community. A critical problem is to
find the optimal match between each individual and that
environment which is most capable of meeting his or her needs--
a task to which research can contribute wisdom and methods.

Reimbursement for Services

 

Availability and use of long-term care services tend to
follow changes in reimbursement mechanisms. Social
experiments are needed to provide the data to analyze the
relationship between various reimbursement methods and the
effectiveness of long-term care and other social services.

Transportation and Communication Services

 

Studies indicate that transportation is least adequate for

the aged groups most in need--the physically frail, persons with-
out family or kin, minorities, inner-city dwellers and the

poor. Improved transportation is a means of linking people

and services. Research and social experiments to create and

test other ways to link people and services are still needed,
including home delivered services of all types and the use

of new technologies, for example cable television and citizen
band broadcasting.

Legislated Social Services

 

Revenue sharing, Title XX of the Social Security Act as amended
in 1975, and similar legislation apparently has not signifi-
cantly increased the level of social services for the elderly.
Research is needed to determine how resources provided in the
legislation can be better deployed on behalf of the elderly.

Social Security

The Social Security system remains a major source of retire-
ment income, replacing an estimated 25 percent of pre-retire-
ment earnings. While Supplemental Security Income is an
29

improvement over Old-Age Assistance, the projected increase
in the number of beneficiaries has not materialized. Research
is needed on

o the reasons--including institutional problems--why
greater numbers of qualified individuals have not
applied for Supplemental Security Income

o improved techniques for informing and registering
those who are qualified for SSI

Medicare

Medicare, providing third-party payments of certain health
costs, has obviously helped our older citizens. But increas-
ingly, it pays less of the older person's health bill and
seems to be least adequate in the most serious area--long-
term care. Continuing research and analysis of Medicare's
drawbacks and of possible remedies are needed.

Comprehensive Services

 

To respond to the growing needs of present aged and the
increasing number of future aged, research in the delivery
of comprehensive services is urgent. No community in the
U.S. has a full range of services for the aged, and limited
social experiments have not adequately documented the
optimum range and mix of health and social care programs.
While many of the findings of these experiments have been
useful in planning and policy development, what we do know
is small compared to what we do not know.

Studies of options for providing continuity of care, inclu-
ding preventive and rehabilitative care and methods for
organizing and financing services and their delivery, that
can yield practical benefits for the care of older Americans,
remain to be conducted. Two promising models for experimen-
tation are:

o "one stop" centers, perhaps sited at specially
designed housing for the elderly, to which the
elderly can come with a minimum of travel and
inconvenience

o a new type of "health maintenance organization"
for older people that provides physical and
mental health care, social services, financial
assistance, and aides for those who need help
with personal and household services

Experiments on these and other models could address such
questions as what are suitable mixes of a range of services:
What impact does integration of services have on the older
individual? How does integration affect use of services and
cost efficiency? What is the role of voluntary groups and
agencies? What is the appropriate role of family, ethnic and
neighborhood groups in the provision of services? What is
the cost and effectiveness of alternative models of service
delivery?

bata

Data are needed on what services do exist, their adequacy
and gaps, which are and are not used, and who in the
population uses them. More exact demographic and epidemi-
ologic information about population trends is also needed
to anticipate and prepare for services needed by the futur-
aged.
3

Chapter IV

RESEARCH RESOURCES

 

"The Secretary may also provide training

and instruction and establish traineeships
and fellowships, in the Institute and
elsewhere, in matters relating to study and
investigation of the aging process and the
diseases and other special problems and needs
of the aged." 1/

Reduction of psychological and physical dependency, extension
of active and useful life, prevention and treatment of age-
associated diseases, design of service systems to foster
self-care by the elderly--these and other research priorities
described in the previous chapter require several resources,
including:

o well-trained investigators given the opportunity
to do research on aging and the problems of the
aged

o animal and human populations in which the normal
and abnormal aspects of aging may be investigated

o basic data--demographic, epidemiological, clinical--
needed to shape research programs and determine
their effectiveness

MANPOWER: EDUCATION AND TRAINING

The Research on Aging Act of 1974 specifies two purposes for
advanced education and training in age-related areas:

o as preparation for research on "the aging process
and the diseases and other special problems and
needs of the aged"

0 "to ensure the education and training of adequate
numbers of allied health, nursing, and paramedical
personnel in the field of health care for the aged"

 

1/ The Research on Aging Act of 1974, P.L. 93-296
32

With the present size and prospective growth of the aged popula-
tion, gerontologic research is an undeniable need. The essential
element in fulfilling that need is a research community--a
sufficient number of highly trained biologists, chemists,
physicians, sociologists, psychologists, economists, and others--
with a long-range career commitment principally to research

on the process of aging and the needs of the aged.

The question of what is a "sufficient number’ brings in the
stipulations of the Research Training Act of 1974, which mandated
that the Secretary of the Department of Health, Education, and
Welfare "arrange for the conduct of a continuing study to establish
(a) the Nation's overall need for biomedical and behavioral
research personnel, (b) the subject areas in which such personnel
are needed and the number of such personnel in each area, and

(c) the kinds and extent of training which should be provided

such personnel "

The "continuing study’ is being conducted for the Secretary of
the Department of Health, Education, and Welfare by a committee
of the National Research Council. In its first report, issued
in 1975, the committee emphasized the importance of training
grants for modulating the supply of trained researchers--MDs
and PhDs--in various fields, including biomedical, behavioral,
and health services. The report emphasized the considerable
flexibility provided by postdoctoral training: "Support of
postdoctorals does not increase the manpower pool, but provides
for its improvement and for diversification into more applied
areas of special importance . . . [P]ostdoctoral training pro-
grams provide the means for preparing researchers more rapidly
for emerging and recently recognized priority areas."

The 1976 report of the National Research Council repeated

this emphasis on post-doctoral training, and, of special
pertinence to research on aging, noted that the "opportunity
for M.D. and Ph.D. graduates to be trained together during the
post-doctoral period is widely regarded as a valuable aspect
of this experience."

While postdoctoral training grants are certainly an effective
mechanism for increasing the numbers and competence of trained
researchers on aging, other support mechanisms are also important,
including predoctoral and institutional training grants. Train-
ing grants can also be used to catalyze the creation of graduate
and postgraduate programs that focus on the interdisciplinary
aspects of research on aging.
33

whatever mechanism is used, they must assure that the programs
are of uniformly high quality. To quote again from the 1976
report of the National Research Council:

"...the federal responsibility for
health research training goes beyond

the simple assurance of access to
graduate and postgraduate training,

and extends to the provision of programs
that are of a high level of excellence
in areas relevant to the national
interest [emphasis added]."

Remedies which are urgently recommended for alleviating
deficiencies in available trained manpower include:

expansion of the current support of predoctoral, postdoctoral
and institutional training grants for research on aging; expan-
sion of pre- and postdoctoral fellowships and Research Career
Development Awards; and reintroduction of authority to support
Special Fellowships, in order to attract established investi-
gators to research on aging. The dimensions of this urgency
are defined in disciplinary terms as follows:

Biomedical Sciences

In the basic biological sciences, for example, there are currently
no adequate, well-rounded research training opportunities for pre-
and postdoctoral students wishing to specialize in the biology of
aging. Nor is there any existing mechanism for an established
investigator outside of gerontology to enter the field.

 

The manpower needs for clinical research efforts can be met most
effectively by postgraduate training programs that enable young
physicians to apply their knowledge to specific clinical issues.
Such trained researchers would ultimately perform in concert with
the physician, dentist, and nurse to identify and manage clinically
significant changes; to analyze and guide the prevention and
treatment of geriatric infirmities and diseases; and to support
programs that enable the aged to function despite a range of
crippling, usually chronic disorders.

Presently, clinical research training programs are wholly inade-
quate. There is no requirement by any medical schools that

their students receive part of their training within nursing

homes, long-term care institutions or home-care programs. Among

the medical schools there are only two formal training programs

in geriatric medicine, and very few centers in which any sort of
training for research in clinical gerontology can be obtained. This
gap between growing need and the limited number and scope of train-
34

ing programs is especially critical now as more medical schools,
VA hospitals, and other research centers seek to establish co-
ordinated programs on research in aging. Training programs to
meet this growing need for clinical researchers might encompass
a 5-year postgraduate program in internal or family medicine
which emphasizes clinical gerontology and includes didactic work
in a school of public health.

Clinical gerontology should also be a standard part of the graduate

and undergraduate curricula of schools of medicine, dentistry, nursing,
and allied health. By and large medical students now get little

or no exposure to the medical problems of the elderly, a lack
reinforced by the prejudice toward the aged often displayed by

teaching and practicing physicians. The introduction of clinical
gerontology into curricula may also reinforce a principle that

applies to other areas of clinical medicine--that more attention

must be given to the prevention of illness rather than simply its
treatment.

Behavioral and Social Sciences

 

Training programs are needed that will enable graduate and post-
graduate students to apply their education to basic and applied
research issues in aging. Such training programs should emphasize
the interdisciplinary nature of many issues in aging; for ex-
ample, the valuable insights provided when psychologists, econo-
mists, and sociologists cooperatively probe the factors that
create dependencies in aging individuals and groups.

Human population studies that deal with the social and psychological
problems of aging such as grief, loss of family roles, or the end

of regular employment provide the opportunity to improve the quality
of life for the elderly and may help unlock some of the problems
that beset our young and middle-aged populations.

Human Services and Their Delivery

 

A professional cadre is needed concerning itself with research
on how services are planned, organized, delivered, and evalu-
ated. It must design programs that can deliver effective medi-
cal, social, economic and other support services to the elderly
against a backdrop of limited funds, shifting national and local
priorities, insufficient chronic care facilities, and various
cultural and social settings. Such program design must be
sensitive to the problems of many of the elderly--inadequate
housing, income, medical care, nutrition, and social services.
35

Graduate and postgraduate students as well as established pro-
fessionals must be provided training for research on admini-
strative, political, social, health care and other service
systems. And, again, mechanisms must be created for a multi-
disciplinary approach where needed.

Research on Education and Manpower

 

The specific needs for education and manpower in different
fields pertinent to research on aging must be supplemented by
research on:

o the educational process—-to test, evaluate, and
develop methods and models of gerontologic and
geriatric training

o manpower needs—-to analyze tne types and numbers of
personnel required now and in the future to meet
specific needs for researchers described above

RESEARCH MECHAN1SMS AND TOOLS

Effective research requires not only competent manpower but
also mechanisms and tools suited to the problems to be ad-
dressed. Mechanisms include regional and university-based
research centers where many can focus on a particular problem.
For example, recent studies on alcohol and aging required the
collaboration of clinical gerontologists, physiologists, phar-
macologists, biomathematicians, and experimental psychologists.

While a few centers do exist, most gerontologists still work
separately and in relative isolation. Lack of centers also
reduces the opportunities for collaborative research and the
likelihood of attracting to gerontology able investigators from
other fields. Such regional, university-based research centers
would not only provide foci for the concentration of a small
pool of first-class talent, but would also provide more
effective training for students, as well as easier access to
necessary resources at reduced cost.

Experimental Resources

 

Human population groups are the most important single experi-
mental resource in aging research. Finding such groups, re-
cruiting them, and gathering the needed data is difficult and
often expensive. The effort may require, particularly in
longitudinal studies, literally a lifetime of work--an extra-
ordinary commitment by investigators, research subjects, and
funding agencies. Yet such studies, cross-sectional and longi-
tudinal, can now be done with greater accuracy and with a
36

larger yield of data than was possible 10 years ago. The
discussion of research priorities in Chapter III delineated
the promising issues which can be addressed by such studies.
For example, aging and atherosclerosis are separate, distinc-
tive processes, but their frequent association complicates our
understanding of the two basic processes involved--one leading
to a normal stage of human development and the other to dis-
ease. Longitudinal studies of biochemical, physiological,
social and behavioral characteristics on populations largely
free of atherosclerosis could add enormously to our under-
standing. Such studies could provide measures of the normal
aging process, including the rates of biological aging, in-
dependent of the effects of the common chronic diseases of
middle- and old-age. Typical of other questions that can be
asked are:

o what living arrangements for the elderly produce
the greatest life satisfaction and the lowest rates
of morbidity and mortality?

o what is the relationship of socioeconomic status
to differences in longevity between men and women?

A small number of population laboratories seems to be the best
mechanism for carrying out large-scale population studies.
Such laboratories must have:

o cooperative and adequately large populations suited
to the questions to be studied

o sophistication in demography, epidemiology, bio-
statistics, and computer sciences

o investigators willing to make a long-term commitment
--over a decade--to studies of human populations

o long-term commitment of uninterrupted financial
support

Animal Populations

A wide variety of organisms other than humans are or should be
used in aging research. These include animals such as subhuman
primates, pedigreed dogs, rats and mice; metazoa such as nema-
todes, protozoa such as the ciliates and the amoebae, and
cultured mammalian cells.

Rats and mice are useful and popular in aging rese~rch because
they have short lives, cost comparatively little, and can be
genetically defined. Moreover, colonies of rats, mice and sub-
37

human primates can be reproducibly maintained in institutional
and commercial facilities for shipment to investigators. How-
ever, the availability of such colonies is at present extremely
limited; only two NIH-supported colonies of rodents for use in
aging research now exist. These do not meet the present demands
of the scientific community, much less their projected needs.

Thus, there is an urgent need for regional animal distribution
centers to facilitate and encourage the interest in aging
research generated the past five years. Similarly, support of
existing subhuman primate centers should be vastly increased
the next several years.

Different in scope but equally essential to aging research is
the maintenance and expansion of existing banks of cultured
mammalian cell lines. The availability of such cell lines has
already spurred new directions in aging research, including:

o analysis of the biochemical similarities and
differences among cells taken from species with
different life spans

o establishment of cell banks as repositories for
cells taken from individuals afflicted with genetic
diseases related to premature aging, such as
Werner's syndrome and progeria.

INFORMATION SYSTEMS AND RESEARCH EVALUATION

To improve the effectiveness and efficiency of research we
should have:

o an inventory of research projects underway or
completed

o access to data from prior research surveys,
censuses, and so on

Inventory of Research

 

A centrally-available index on prior and current research is
important to a field such as aging that cuts across many re-
lated subjects and disciplines. A system for maintaining a
continuing inventory of research in aging could help to:

o avoid unwarranted duplication of research

o identify trends and patterns or reveal gaps
in efforts
38

o stimulate new ideas for research planning or
for innovations in experimental techniques

o provide a resource for technological forecasting
and development

Such a central inventory could link with more generalized
research inventories--e.g., the Smithsonian Science Informa-
tion Exchange (SSIE) and the Computerized Retrieval of
Information on Scientific Projects, NIH (CRISP).

An inventory of aging research (other than biomedical) has
recently begun. This "Comprehensive Inventory and Analysis of
Past and Current Federally Supported Research in Aging,"
sponsored through contract by DHEW's Administration on Aging,
will cover the past 10 years.

Data Banks

Data collections which have potential utility for research on
the biomedical, psychosocial, and service delivery aspects of
aging exist in various forms and at various sources. They may
or may not be identifiable as being addressed to aging, yet an
aged group might constitute a significant portion of a total
population or sample under study. The data may represent one-
time or continuous studies, longitudinal or cross-sectional
designs, general purpose or program-oriented statistics,
national, local or even narrower populations.

An extremely useful resource would be a data index to aging-
related statistics from research studies and from data col-
lection sources such as the Bureau of the Census, the

National Center for Health Statistics, and the Social Security
Administration.
 

 

 

y SECRETARY
SPECIAL ASSISTANTS: EXECUTIVE ASSISTANT
WELFARE MATTERS TO THE SECRETARY
UNDER SECRETARY

 

 

 

 

EXTERNAL AFFAIRS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CON rae 0 ne EXECUTIVE SECRETARIAT OFFICE FOR CIVIL RIGHTS
oi ' Executive Secretary Director
irector,
1 L I [ 1 1
ASSISTANT SECRETARY ASSISTANT SECRETARY ASSISTANT SECRETARY CENERALCOUNSEL i AN] JacneTAny ASSISTANT SECRETARY,
(LEGISLATION) (PUBLIC AFFAIRS) (PLANNING AND EVALUATION) YR Adm SIRaTY COMPTROLLER
: SOCIAL AND SOCIAL SECURITY
ASSISTANT SECRETARY FOR ASSISTANT SECRETARY ASSISTANT SECRETARY
SAN DEVELOPMENT FOR HEALTH REHABILITATION SERVICE FOR EDUCATION ADMINISTRATION
Administrator Commissioner

 

 

 

 

 

 

 

| | |

EDUCATION DIVISION

 

 

 

 

 

 

 

 

 

 

OFFICE OF PUBLIC HEALTH SERVICE
HUMAN DEVELOPMENT
CENTER FOR DISEASE CONTROL OFFICE OF EDUCATION
ADMINISTRATION ON AGING Director, Commissioner,
Commissioner,
OFFICE OF F000 AND O30 HOF EouCATION
CHILD DEVELOPMENT ’ Director,
Commissioner,
Director,
OFFICE OF HEALTH RESOURCES
YOUTH DEVELOPMENT ADMINISTRATION
Director, Administrator,
WN. oi HEALTH SERVICES Figure 5. Organizational Chart of the
ADMINISTRATION
Duector, Administrator, Department of Health, Educa-
OFFICE FOR NATIONAL INSTITUTES tion, and Welfare.
HANDICAPPED INDIVIDUALS y : To
Director, OF HEALTH Agencies with significant
_. \ Director, programs in aging research
PRES. COMMITTEE O ;
MENTAL RETARDATION ALCOHOL, DRUG ABUSE, shown in bold-face type.
Exscuve Dinectar, AND MENTAL HEALTH
ORF ICEOF oo DAINISTAATION
NATIVE AMERICAN PROGRAMS :
Chester, PRES. COUNCIL ON
PHYS. FITNESS & SPORTS
REHABILITATION SERVICES Executive Director, w
ADMINISTRATION O
Director,

 

 

 

 

REGIONAL OFFICES
Regional Directors

 

 

 
40

CHAPTER V
BRIEF LEGISLATIVE HISTORY OF

RESEARCH IN AGING WITHIN HEW

"The Congress finds and declares that . . .
there is no American institution that has
undertaken comprehensive, systematic, and
intensive studies of the biomedical and
behavioral aspects of aging and the related
training of necessary personnel."

The DHEW (Figure 5) has a broad array of research authority.
The focus of this presentation is limited to the main legisla-
tive authority for research efforts in aging within the
Department. It may omit some additional research authority
which might conceivably be utilized for age-related research.

PUBLIC HEALTH SERVICE (PHS)
The National Institutes of Health (NIH)

The Public Health Service Act (Sec. 301) is the legislative
source of the National Institutes of Health's basic research
authority. Since the passage of the PHS Act there have been
further enactments which increased the number of Institutes
to the present level of 11 Institutes (Figure 6). Prior to
1962, each of the Institutes was limited to research in a
disease category. In 1962, an amendment (P.L. 87-838) to the
PHS Act created the National Institute of Child Health and
Human Development (NICHD) to provide for research into "the
process of human growth and development.'" The creation of
NICHD allowed for research into both normal and abnormal
development of the human being and expressly declared that it
include such fields as child health, prenatal development,
maternal health, and aging. (1) The Report of the House

 

1/ The Research in Aging Act of 1974, P.L. 93-296
 

DIRECTOR
DEPUTY DIRECTOR

 

DEPUTY DIRECTOR

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

1 (Science)
ASSOCIATE DIRECTOR FOR ASSOCIATE DIRECTOR FOR
EXT. RES. & TRAINING PROGRAM PLAN. & EVAL.
ASSOCIATE DIRECTOR FOR ASSOCIATE DIRECTOR FOR
COLLABORATIVE RES. ADMINISTRATION
ASSOCIATE DIRECTOR FOR ASSOCIATE DIRECTOR FOR
CLINICAL CARE COMMUNICATIONS
ASSISTANT DIRECTOR FOR
INTRAMURAL AFFAIRS
NATIONAL NATIONAL NATIONAL
CANCER HEART, LUNG, & BLOOD LIBRARY OF
INSTITUTE INSTITUTE MEDICINE

 

 

 

 

 

 

 

 

 

 

|

NATIONAL INSTITUTE ON
AGING

 

 

 

 

I

NATIONAL INSTITUTE OF
ALLERGY & INFECTIOUS
DISEASES

 

 

 

|

NATIONAL INSTITUTE OF
ARTHRITIS, METABOLISM, &
DIGESTIVE DISEASES

 

 

 

 

 

[

NATIONAL INSTITUTE OF
CHILD HEALTH &
HUMAN DEVELOPMENT

 

 

|

NATIONAL INSTITUTE OF
DENTAL RESEARCH

 

 

1

NATIONAL INSTITUTE OF
ENVIRONMENTAL
HEALTH SCIENCES

 

 

 

I

NATIONAL INSTITUTE OF
GENERAL MEDICAL

 

 

 

 

NATIONAL INSTITUTE OF
NEUROLOGICAL AND
COMMUNICATIVE DISORDERS

 

 

 

 

 

1

NATIONAL EYE INSTITUTE

 

 

 

 

 

 

 

 

 

 

 

SCIENCES
AND STROKE
DIVISION OF FOGARTY
DIVISION OF DIVISION OF DIVISION OF
CLINICAL CENTER COMPUTER RESEARCH RESEARCH GRANTS RESEARCH RESOURCES RESEARCH SERVICES INTERNATIONA,
& TECHNOLOGY CENTER

 

 

 

 

 

 

 

 

Figure 6.

Organizational Chart of the National Institutes of Health.

19
42

Committee states that the NICHD will be authorized to conduct
research and training in "studies in the biological, medical
and behavioral aspects of aging." The House Report further
states that:

The proposal to depart from the disease
category approach in the establishment

of the proposed new Institutes (NICHD and
NIGMS) does not reflect any intent--

either on the part of the Committee or the
Department--to curtail or de-emphasize
research activities of existing categorical
Institutes . . . . Rather it is the objective
of this legislation to reinforce the existing
structure of categorical Institutes by pro-
viding for proper administrative coordination
of research activities in two broad areas of
research which--although not focused on a
particular group of diseases-—are essential
to any broad advance in the health sciences. (2)

The Senate Report on the NICHD authorization stated that:

The Institute's attention will be focused,
not on any one disease or part of the body,
but rather on the whole person, with its
complex of health problems and requirements.
There will be emphasis, for example, on the
special health status and needs of particular
segments of the population--e.g., infants,
adolescents, expectant mothers, and aged
persons--with common health problems which
lend themselves to intensive study. [emphasis
added] (3)

In 1971, the White House Conference on Aging recommended that
a National Institute of Gerontology be established to support
and conduct research and training in the biomedical and
social-behavioral aspects of aging. Congress passed such a
bill in 1972 but it was pocket-vetoed by the President. A
similar bill was again introduced in 1973 and enacted into
law in 1974 as the Research on Aging Act of 1974. This
statute created the National Institute on Aging by adding

new sections (Sec. 461-464) to the Public Health Service Act.
43

The statute establishing the NIA directs that the Institute
conduct and support biomedical, social, and behavioral
research and training related to the aging process and the
diseases and other special problems and needs of the aged.

The legislative history of the Act reveals that both the

House and Senate Committees felt that research into aging

was important enough to grant it an independent status

within the organizational structure of the National Institutes
of Health. (4)

The issue of overlapping jurisdiction and duplication of
effort by the new Institute was raised and addressed in the
House Report, and in the Floor debate. The Committee stated
that the bill provided the Secretary with authority to (1)
assign responsibility for research and training to the new
Institute or another Institute, or to both of them and (2) be
responsible for coordinating such activities so as to avoid
unproductive and unnecessary overlap and duplication. (5)

Health Resources Administration (HRA)

 

The Health Resources Administration operates under the author-
ity of the Public Health Service Act, Sec. 304-306. These
sections authorize the Secretary to undertake through the
National Center for Health Services Research and the National
Center for Health Statistics and any other units of the
Department, the conduct, support and coordination of health
services research, evaluation, and demonstrations, as well as
health statistical activities. The same Act also authorized
the Secretary to coordinate in the same context, health services
research, evaluation and demonstration with the experiments and
demonstrations authorized by the Social Security Act and the
Social Security Amendments of 1967. (6)

The enactment of the Partnership for Health Amendments of 1967
provided a Government-wide focus for health services research.
The Health Services Research, Health Statistics and Medical
Libraries Act of 1974, revised and extended the programs of
health services research. In addition, the Center for Health
Services Research was given the responsibility for the devel-
opment of an overall health services research strategy and
provided for the coordination of health services research
activities for the entire Department. (7)
44

Health Services Administration (HSA)

 

The primary mission of the various Bureaus within HSA is

the actual delivery of services or the support through
grants, contracts, and other arrangements to provide
services. HSA thus tends to be a utilizer of research to
improve health care delivery. The legislative mandate for
HSA is found primarily in the Public Health Service Act

and the Social Security Act. The research and development
aspects of health services were separated with HSA having
responsibility for health delivery and health service system
development.

Alcohol, Drug Abuse & Mental Health Administration (ADAMHA)

 

ADAMHA is comprised of three Institutes—-National Institute on
Alcohol Abuse and Alcoholism, the National Institute on Drug
Abuse, and the National Institute of Mental Health. Each
Institute has research authority with implications for researct
in the field of aging (Figure 7).

The National Institute of Mental Health was created by Sec.
455 of the Public Health Service Act. It also functions
under the Mental Retardation Facilities and Community Mental
Health Centers Construction Act of 1963. NIMH carries on a
broadly based research and development program. (8)

The legislative history indicated concern over the increasing
age of the population and the implication for mental health
research stating:

There is evidence also, that the number of
mental cases is increasing out of proportion

to the population increase. While the rate

for a given age group is probably no higher
than in the past, the rapid increase in the
average lifespan is probably responsible for
this rise since the incidence of mental disease
increases with age. The number of persons

age 65 and over is expected to double within
the next 10 years, as compared with an overall
population increase of only about 23 percent.
Unless positive steps are taken, we must,
therefore, expect the problem of mental diseases
to increase as our population grows older. (9)
 

 

OFFICE OF THE ADMINISTRATOR

 

 

 

I
L

 

ADAMHA

 

 

 

I Equal Employment |

Opportunity

 

 

 

 

 

 

 

OFFICE OF PROGRAM
PLANNING AND EVALUATION

OFFICE OF PROGRAM
COORDINATION

 

 

 

 

OFFICE OF ADMINISTRATIVE
MANAGEMENT

 

OFFICE OF COMMUNICATIONS
AND
PUBLIC AFFAIRS

 

 

 

 

 

 

 

 

 

 

 

NATIONAL INSTITUTE ON
ALCOHOL ABUSE AND
ALCOHOLISM

 

 

NATIONAL INSTITUTE ON
DRUG ABUSE

 

 

NATIONAL INSTITUTE OF
MENTAL HEALTH

 

 

 

 

Figure 7. Organizational
Alcohol,

search

within the
Health.

Mental

Drug Abuse,
Health Administration.

National

Chart of the

and Mental
Aging re-
is a significant component
Institute of

 

DEC. 1975

 

 

 

Gh
46

In 1975, NIMH established a new Center for Studies of the
Mental Health of the Aging. The Center will develop, co-
ordinate and evaluate programs of research, training, and
services related to the mental health of the aging. Another
activity will be holding national conferences to provide

a forum for the exchange of ideas and information in this
growing area of concern.

The other two Institutes within ADAMHA--the National Institute
on Drug Abuse and the National Institute on Alcohol Abuse

and Alcoholism--have implications for research in aging
although the authorizing legislation does not specifically
make reference to the aged but applies to all segments of the
population.

Food & Drug Administration (FDA)

 

The FDA has broad research authority, none of which is spec-
ifically age-related. The mission of the FDA, as the
government's primary consumer protection agency, is to
protect the public from impure, ineffective, or impaired
foods, drugs, biological products, poisons, pesticides, and
food additivies. The FDA is also authorized to ensure that
all of the products that it regulates are honestly and
informatively packaged. (10) Many of the products which the
FDA analyzes have a significant impact on the elderly users,
particularly drugs, since the elderly are disproportionately
greater users.

OFFICE OF HUMAN DEVELOPMENT (OHD)

The OHD, another major unit within the Department of HEW, is
described as having responsibility to "help Americans with
special needs." The two most significant agencies, in terms
of the aged, under the OHD are the Administration on Aging
(AoA) and the Rehabilitation Service Administration (RSA).

Administration on Aging (AoA)

 

The Older Americans Act of 1965, as amended provides authority
for training and research and development in specific areas

of concern, e.g., to study current patterns and conditions of
living of older persons, to develop and demonstrate new
approaches, techniques, and methods which hold promise

of substantial contribution toward wholesome and meaningful
living and for coordination of community services for older
persons.
47

Impetus for the creation of the AoA resulted from the White
House Conference on Aging in 1961. The original statute
gave the AoA the authority to assist the Secretary in all
matters pertaining to the problems of the aged and aging.

The Senate Committee was impressed with the success of the
projects supported by AoA so that in 1967 the appropriations
for research and demonstrations were increased. (11)

In 1973 amendments to the Act made considerable changes in
the entire structure of the AoA and added significantly to
its research mandate through the authorization of Multi-
disciplinary Centers for Gerontology. The mandate of the
Centers include:

The conduct of basic and applied research

on work, leisure, and education of older
people, living arrangements of older people,
social services of older people, the eco-
nomics of aging, and other related areas. (12)

In addition, these centers are charged with the responsibility
of stimulating "the incorporation of information on aging

into the teaching of biological, behavioral, and social
sciences at colleges or universities'" and "also, to create
opportunities for innovative, multidisciplinary efforts in
teaching, research and demonstration projects with respect

to aging." (13) The multidisciplinary centers were created

in response to the results of a study on the need for trained
personnel in the field of aging, mandated by the 1967
Amendments to the Older Americans Act.

This study notes that a major hindrance to the development of
such centers has been the lack of general purpose financial
support from the Federal Government, which limits its aid to
funding specific research and training projects. (14)

A new and expanded evaluative function was also added to the
Act which granted the AoA the authority to:

carry on a continuing evaluation of the
programs and activities related to the
purpose of this Act, with particular
attention to impact of Medicare and Medicaid,
the Age Discrimination Act of 1967, and

the programs of the National Housing Act
48

relating to housing for the elderly

and setting standards for the licensing

of nursing homes, intermediate care

homes, and other facilities providing care
for older people. (15)

The 1975 amendments to the Act extend gerontological train-
ing and research authority for an additional two years and
also authorizes a new research area, namely, the legal
problems affecting older persons.

Rehabilitation Services Administration (RSA)

 

The Rehabilitation Act of 1973 consolidates all research and
training authority of predecessor legislation. This Act
provides authority to develop new applications of the most
advanced medical and rehabilitation technology and services

to help handicapped persons through research, special projects
and demonstrations. (16)

The Act consolidates four areas of special emphasis into a
single special project authority (Title III), including
projects for older blind individuals.

SOCIAL SECURITY ADMINISTRATION (SSA)

The Social Security Act of 1935 granted the Secretary the
authority to study and make recommendations as to the most
effective methods of providing economic security through
social insurance.

In 1956, provision was made for cooperative research and
demonstration projects (P.L. 84-880, Sec. 1110) that would
lead to the prevention and reduction of dependency. One
change of significance was made in Sec. 1110 (P.L. 90-248)

by granting specific authorization for research to the Social
Security Administration separate and distinct from that of
the Social and Rehabilitation Service. (17)

With the advent of Medicare and its administration by the
Social Security Administration came additional research
authority in the form of Section 1875. This section provides
authority to make studies and develop recommendations to be
submitted to Congress related to the health care of the
aging, including studies and recommendations concerning
49

the adequacy of existing personnel and facilities for health
care for the purposes of programs under Title XVIII; methods
for encouraging economical alternatives to in-patient
hospital care; and the effects of the deductibles and co-
insurance provisions upon beneficiaries, providers of
services, and the financing of the program. (18)

With the enactment in 1972 of P.L. 92-603, Sec. 222 provision
was made for demonstration projects designed to determine the
relative advantages and disadvantages of various alternative
methods of making payments on a prospective basis to hos-—
pitals, skilled nursing facilities, and other providers of
services for care provided by them under Title XVIII of the
Social Security Act as well as Title XIX and V of the Act.
Also included, were demonstrations of homemaker, day care,
and extended care projects. These projects have great
potential for the health care of the aged. (19)

OFFICE OF EDUCATION

The inclusion of research authority of specific concern to
aging within the education programs administered by the
Department is a relatively new development. In 1973, Public
Law 93-29, the Comprehensive Ulder Americans Act Amendments,
added a new Section 110 to Title I of the Higher Education

Act of 1965. (20) The House and Senate Reports are almost
identical in their language calling for grants to institutions
of higher education to plan, develop, and carry out programs
specifically designed to apply the resources of higher educa-
tion to the problems of the elderly.

Public Law 93-29 also included an amendment to the Adult
Education Act which added a new Section 310 authorizing
special projects for the elderly and programs for those
elderly persons whose ability to speak and read the English
language is limited and who live in areas with a culture
different from their own. (21)

The Vocational Educational Act of 1963 as amended provides for
research in specified areas, i.e., consumer and homemaking
programs, etc. (22)
50

The National Institute of Education and the Fund for the
Improvement of Post Secondary Education, created by

P.L. 92-138, provides for educational research and develop-
ment. Although no specific reference is made to the aged,
its mandate provides for individuals of all ages and
circumstances. (23)

ADVISORY BODIES AND COORDINATION

 

The two main advisory groups in aging are the Federal Council
on Aging (FCA) created in 1973 and the National Advisory
Council on Aging (NACA) created in 1974. The role of the FCA
is to advise the President, Secretary, Commissioner on Aging,
and Congress. The FCA also has been authorized to undertake
studies which promote the interests of the aged with several
areas specified, i.e., the interrelationship of benefit
programs for the elderly, the impact of all taxes on the
elderly, and the effects of formula grants. While the FCA
may conduct studies, it is not an operational agency which
supports research. (24) Its primary focus is oversight or
advocacy on behalf of the aged.

The NACA's role is to advise, consult with and make recom-
mendations to the Secretary on programs relating to the aged.

The legislation also requires the Secretary in consultation

with the National Institute on Aging and the NACA and such other
appropriate advisory bodies to develop a plan for a research
program on aging designed to coordinate and promote research into
the biological, medical, psychological, social, educational, and
economic aspects of aging. (25) This (one time) plan for a
research program on aging is to be transmitted to Congress

and to the President.

The legislation also provides for ex officio members on the
NACA. Administratively, this has provided for representations
from the FCA and other agencies both within DHEW and

other Federal agencies. The various pieces of legislation
cited in this report direct the Secretary to coordinate

the Federal programs within the Department. Coordination

is primarily achieved through providing ex officio (Federal)
representatives on the NACA, and through the Interagency
Committees authorized under the Older Americans Act, as
amended.
51

SUMMARY

The foregoing discussion has attempted to highlight the

more significant items of legislation and agencies that have
age-specific and age-related authority for research. While
there is a possibility for overlap and/or duplication, this
is minimized because the focus of the research authority
varies sufficiently; the field is broad and multidisciplinary

in nature; and the resources for research in aging have been
limited.
52

(1)
(2)
(3)
(4)
(5)
(6)

£7)
(8)

(9)

(10)

(11)
(12)
(13)
(14)
(15)
(16)
(17)

(18)

References

H.R. Rep. No. 1969, 87th Cong., 2d Sess. 1-2 (1962).
Id. at 3.

S. Rep. No. 2174, 87th Cong., 2d Sess. 3 (1962).
H.R. Rep. No. 93-906, 93rd Cong., 2d Sess. 3 (1974).
S. Rep. No. 93-299, 93rd Cong., lst Sess. 4 (1973).

Public Health Service Act §§ 304-306, 42 U.S.C.
§§ 242b-d (1974).

H.R. Rep. No. 538, 90th Cong., lst Sess. 17 (1967).

Public Health Service Act § 455, 42 U.S.C. § 289k-1
(1968).

S. Rep. No. 1353, 79th Cong., 2d Sess. 3 (1946).

Directory of Federal Technology Transfer, supra note 27,
at 92.

 

S. Rep. No. 367, 90th Cong., lst Sess. 3 (1967).
Older Americans Act § 421(1)(B), 42 U.S.C. § 3031 (1974).
1d.

H.R. Rep. No. 93-43, 93rd Cong. lst Sess. 20 (1973).
Older Americans Act § 202(14), 42 U.S.C. § 3012 (1965).
Op. Cit. at 105.

Social Security Act § 1110, 42 U.S.C. § 1310 (1956).

Social Security Act § 1875(a), 42 U.S.C. § 1395(11)
(1965).
(19)

(20)

(21)

(22)

(23)
(24)

(25)

53

Social Security Act Amendments of 1972 § 222, 42 U.S.C.
§ 1395 (1972).

Higher Education Act of 1965 § 110 as amended by
Public Law 93-29, 20 U.S.C. § 1008a(b) (1974).

Adult Education Act § 306(a)(4), 20 U.S.C. § 1205
(1974).

Vocational Education Act § 161(d)(2), 20 U.S.C. § 1341(d)
(1974).

Public Law 92-318 §§ 404-405, 86 Stat. 235 (1972).
Older Americans Act § 205, 42 U.S.C. § 3012 (1974).

Public Health Service Act §§ 461-464, 42 U.S.C.
§§ 289k-1-5 (1974).
54

Chapter VI
RESEARCH COORDINATION

AND RESOURCE NEEDS

"The Secretary shall, through the Institute,
conduct scientific studies to measure the im-
pact on the biological, medical, and psycho-
logical aspects of aging of all programs and
activities assisted or conducted by the
Department of Health, Education, and Welfare." 1/

The discussion of research priorities in the third chapter of
this Research Plan illustrates that the phrase ''Research on
Aging" is an encyclopedic one. It encompasses the most
fundamental investigations of the structure and physiology

of cells; the difficult, at times expensive, and often
lengthy studies of human populations; and the search for

ways to reinforce the ability and willingness of many of

the elderly to care for themselves, to live independent and
satisfying lives.

To begin to address the many meanings implicit in "Research
on Aging' requires an incredibly diverse range of training,
experimental resources, research tactics, and knowledge.

COORDINATION

The wide ranging nature of research on aging has been
recognized by the Congress by its creation of various
agencies, within and without DHEW, that address some aspects
of aging and the problems of the aged. The brief legislative
history given in the previous chapter made clear that while
there are many agencies within DHEW involved in aging
research, each agency has a distinct, clearly identifiable
function; for example:

The National Institute on Aging conducts and
supports biomedical, social, and behavioral
research and training related to the aging
process and the diseases and other special
problems of the aged

 

 

1/ The Research on Aging Act of 1974, P.L. 93-296
35

The Health Resources Administration is
concerned with research in the delivery
of health services for the aged, with
particular emphasis placed on long-term
care, cost-effective and consumer-
acceptable alternatives to institutional
care, and cost-effectiveness and quality
of all health and health-related services

The Health Services Administration is concerned
principally with the delivery and provision of
services, and, as such, is a client of research,
particularly of studies on the improvement of
health-care delivery

The Rehabilitation Services Administration is
primarily concerned with the problems of the
handicapped. As such it addresses many of the
problems of the aged, particularly through its
efforts to foster the development of the most
advanced medical and rehabilitative technology
and services to help handicapped persons

These examples are intended to illustrate that while there
are many agencies within DHEW directly or indirectly
concerned with the aged, they do have unique functions
that may overlap but are not duplicative. Rather,
properly carried out and coordinated, the work of the
various agencies can serve to synergistically raise

the level of the research effort on aging.

Given such considerations, it is recommended that each
agency within DHEW concerned with aging as part of its
mission continue to set its own agenda and priorities,
determine its own staffing needs, and, where appropriate,
formulate, within Congressional and departmental guide-
lines, its own research emphasis as expressed in grants,
contracts, and other support mechanisms as well as in its
efforts to raise the level and quality of trained
research manpower.

However, given the overlapping and often potentially
reinforcing efforts of many agencies, it is also recom-
mended that the existing coordinative mechanisms be
strengthened, and that in particular there be continuing
reliance on the advisory capabilities of the Federal
Council on Aging and the National Advisory Council on
Aging. In addition, it is recommended that the coordi-
native efforts of -the Interagency committees authorized
by the amended Older Americans Act be continued and
expanded.
56

NEEDS

In Fiscal Year 1975, the latest for which actual data are
available, an estimated $25 to $30 million was spent by

DHEW on research directly addressed to various aspects of
aging and tne problems of the aged--in all, about 1 percent
of the total DHEW research budget. This data is based
primarily on information furnished by the agencies parti-
cipating in research on aging as defined above. That amount
is too small by any measure, not least the fact that this
small and quite limited funding is intended to probe issues
and concerns that confront some 10 percent of our population.

Capitalization needs to achieve a base for quality research
on aging include four basic areas: defining and developing
the human and animal populations to be studied; developing
the manpower necessary for research; acquisition of technical
resources and equipment; development of a data base for
determining tactual knowledge about tne aging process that
currently exists; and, of course, establishment of basic
priorities.

It is essential, in the view of the National Advisory Council

on Aging that, given both the opportunities for rapid advance

in knowledge in the field of aging research and the historical
undernourishment of the field, there be a significant national
investment in research directly on aging (here defined as

funds spent directly for research on aging and the aged by
various DHEW agencies). Ine National Advisory Council on Aging,
in its role as advisor to the Secretary, DHEW, recommends

an average increase in funding of approximately $10 to $12 million
per year, beginning in Fiscal Year 1977 and culminating in an
annual funding of $75 to $Y0 million by Fiscal Year 1981.

Approximately 190 manyears were devoted to DHEW activities in
research directly on aging in Fiscal Year 1975. Of this number,
approximately 85 percent was within the National Institutes of
Health, with the other 15 percent allocated in other agencies
within DHEW. In the future there must be a growth in staff
commensurate with the increase in funding in order to utilize
these increases prudently and efficiently.

The number of agencies within DHEW participating in aging
research makes it impossible to break down the above figures
for funding or staffing. The individual agencies within the
57

Department, through the processes of budget, forward planning,
and the Department's manpower management system, will present
specific plans and justification for funds and staffing needs
relevant to the goals of this DHEW Research Plan.

Following this five-year period dedicated to establishing aging
research and achieving the short-term goals of this Research
Plan, a reassessment of the status of aging research will be
necessary to determine whether this capitalization is sufficient
to support the major long-term thrust that will be needed in
future years.

Such recommendations may seem demanding. Certainly they should
and will compete within the overall priorities of DHEW and of the
Federal Government. However, these recommendations are intended
to reemphasize and to overcome the historical underfunding of
aging research; they are intended to provide adequate capitaliza-
tion and to remedy, by accelerated and significant increases

in the budget, our serious neglect of the need to understand

the aging process and the needs of the aged.
58

SUMMARY STATEMENT OF

SELECTED RESEARCH OPPORTUNITIES

We now have an opportunity to extend our knowledge and to
design effective programs to deal with many of the issues that
concern aging and the aged. In some cases, we can move ahead
fairly rapidly, with applicable returns on our research
investment possible within five years; for other issues, their
very complexity mandates a longer, more sustained effort,
although significant improvement in our understanding is
possible within several years.

Some of these issues are listed below, both those amenable to
a short term effort of about five years and those requiring
a long-term investment:

BIOMEDICAL ISSUES
Short-Term

o the decline in immunological competence with aging,
and its implications

o variations in the process of aging and the patterns
of disease among the aged of different ethnic,
racial, and cultural groups and between the sexes

o the interaction of aging and its accompanying
diseases with such external factors as nutrition,
physical fitness, and response to medicines.

o collaborative studies with other Institutes of the
NIH and with other DHEW agencies of diseases more
common to the aged--e.g., diabetes mellitus, senile
dementia (or mental deterioration), atherosclerosis,
and osteoporosis

o effective diagnosis and management of the reversible
forms of senility

Long-Term
o The criteria for healthy and successful aging

o the mutually interacting influences of aging and
disease
59

o influence of cultural background on successful
aging
o personal and economic costs of major diseases in old
age
o prosthetic technology as an aid to the maintenance
of an independent life
BEHAVIORAL AND SOCIAL ISSUES
Short-Term
o the social costs, system costs, and socioeconomic
impact of an increased population of the elderly on
communities, public and private services, and the
elderly
o flexible retirement policies, their advantages and
disadvantages to the society at large and to the aged
o occupational and social roles for older people
o adjustments to crises of the life cycle
o support of income maintenance programs
Long-Term
o relationships among family structure and support,
life styles, and patterns of aging
o middle age as a transition to old age
o personality changes during life, from young adult to
very old age
o improvement and maintenance of memory
o the year 2000: the meaning and impact of the new
age structure on American society
ISSUES IN HUMAN SERVICES AND DELIVERY
Short-Term
o integrated services for the elderly
60

ready access by the elderly to prosthetic aids

structural and fiscal basis for improvements in
Medicare

self care and its relationship to preventive
medicine

living arrangements for the elderly

the family as a health and social service delivery
system

research base for care of the aged under a National
Health Insurance System

educational opportunities for the aged
the environment for long-term care

costs of health care in old age

RESEARCH RESOURCES

Short-Term

Long-Term

o

0

expanded training in geriatrics and gerontology

availability of animal and human populations for
aging studies

information systems and research evaluation

university based and regional centers for research
on aging and the problems of the aged

# U. S, GOVERNMENT PRINTING OFFICE : 1977 725-777/817
 
 
 

 

 

 

 
DHEW Publication No. 77-1096
li iin

029190026