Extending Life, Enhancing Life A National Research Agenda on Aging (1991) / Chapter Skim
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Executive Summary and Recommendations for Funding
Executive Summary and Recommendations for Funding
Pages 1-39
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It is a time for celebration because gains in life expectancy have resulted in an estimated 33 million Americans 65 years old and over, the majority of whom are vigorous and active well into advancer]
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, the present agenda aims to identify priority research on aging in basic biomedical science, clinical science, and behavioral and social studies as they relate to health, health services delivery, and biomeclical ethics. To this end, the Institute of Medicine (IOM)
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Four liaison teams aicled the committee: basic biomedical research, clinical research, social and behavioral research, and health services delivery research. Each of the teams was comprised of experts in their respective fields.
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. BACKGROUND Support for Training and Research in Geriatrics and Gerontology At the heart of health care for the oIcler population are the educational programs that train the professionals who can respond to the health problems of elderly persons and make the scientific discoveries that will improve the quality of life of the later years.
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This percentage and that of all funded approved research project grants on aging `24 percent are slightly lowered due to reapplications (see the latter discussion in the section on recommendations for funding)
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Although mortality rates have fallen in the older generation, with increasing life expectancy, chronic diseases have become a major cause of death and disability. For instance, Rice reported that 40 percent of persons 75 and over had two or more chronic illnesses and that the proportion of the aged population reporting multiple chronic conditions hac!
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Nursing home placement is neecled for those who lack social supports and are most limited in ability to care for themselves. One half of nursing home residents require assistance with five or more activities of daily living tADLs: bathing, dressing, grooming, transferring from bee!
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A model cleveloped by Manton describes the potential of intervention to improve the quality of life for oilier persons. If medical care fails to diminish the incidence of disease among oIcler persons, therapy that reduces lethal complications of disease may increase life expectancy in this group, but at the high cost of prolonging chronic illness ant]
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Basic biomedical science can substantially improve the quality of life for older persons, and add to the list of social ant] medical advances in which the nation takes pride, advances that eliminated so many of the killing and crippling diseases of childhood and younger adults.
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Adclitiona i Research Opportunities The research priorities in basic biomedical science listec! above merit primary consideration for implementation, but other promising areas of biogerontological investigation, discussed at length in
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The committee emphasizes that additional resources to support research on aging should supplement, not supplant, existing support for current basic research, either in aging or in other areas of biological investigation. Resource Recommendations First in importance, increase the funding of NIA and other NIH approved investigator-originated research proposals on aging from the present level of one in four to one in two.
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· Increase support to train an additional 200 basic biomedical scientists per year in gerontology. Clinical Research The rapid growth of clinical research in geriatric medicine in the past decade has yielder!
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rehabilitation of disability. Second, studies should examine the effectiveness of various disease prevention strategies for elderly persons and the extent to which preventive interventions may forestall late-life disabling conditions that begin in earlier life.
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· Cardiovascular disorders: Cardiovascular disease is the major cause of death in older persons and is a leacling cause of chronic illness and disability. Research should explore genetic and other risk factors as well as the molecular basis of atherosclerosis; the clevelopment of standard and recombinant-based drug technologies along with gene therapy approaches ant!
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Further examples of research include topics such as whether vaccines can bypass the need for immune T cells and whether vaccines macle with live attenuated organisms, vaccines with antiidiotypic antibodies, or vaccines with antigens attached to a rigic! molecular backbone are effective in elderly persons.
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Behavioral and Social Research Fundamental advances in the study of aging have shown that psychological and behavioral variables, along with factors in the social and physical environment, can alter the course of aging dramatically. Thus, the process of aging is highly responsive to social ant!
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Because individuals adjust to biological decline in aging, behavioral decline often is minimal. Aspects of differentiation in elderly persons also involve variations in individual and cohort lifestyles, risks of illness and dependency, and functional capacity.
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Clinical research should apply what is known about the modifiability of risk factors, skills, learning, and memory. Despite recognition that the major health problems of older people are chronic, little attention has been pail!
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Ac1ditiona] Research Opportunities Opportunities for social research include the following: · study of the characteristics of employment, work places, and older individuals associated with continued productive activity in lifelong jobs or in new careers; · study of how older people are affected Expected and actual performance by changing technology, and how firms use training and job respecification to make technological changes as age neutral as possible; and · development of a quality of life index to identify contributing
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Behavioral and social research will require substantial addecT funds during the first 5 years of the new research agenda, especially to raise funding for approved NIH research proposals on aging from one in four to one in two. Because much of the support for behavioral and social studies in aging comes from agencies outside the NIH (e.g., the Health Care Financing Administration ant!
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factors influencing the recruitment, training, retention, and quality of providers of formal and informal Tong-term care. The costs and financing of Jong-term care Research is recommended on existing barriers to care of oilier persons, the requisite financial elements of insurance programs to support Tong-term care, mental health services, rehabilitation, and disease prevention and health promotion.
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Resource Recommendations To implement the health services delivery research program the committee recommends additional funds to t1) provide support for research grants on aging to increase the current level of support for approved grants from one in four to one in two, (2)
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Finally, there is a need to determine the most ethical way to do research on older persons who are institutionalized, frail, or cognitively impaired. Priority Research Recommendations Funds should be provided to conduct analytical and empirical research on biomedical ethical issues in three priority areas: Dilemmas regarding Jife-sustaining treatment ABocations of health care resources Participation in clinical research by frail emery persons Additional Research Opportunities These opportunities include: · study of cTinician-patient interaction regarding life-sustaining technologies; · research into decision making for incompetent patients who lack advance directives; · study of the role of institutional ethics committees; · the identification of medical futility; · study of resolution of disagreements between caregivers and patients or their families;
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Resource Recommendations Although the NIH National Center for Human Genome Research recently set aside 3 percent of its funds for the study of ethical issues, which could include ethical issues in the care of older persons, the committee knows of no other federal support for research on ethics and geriatric patients, and it strongly encourages funding in this area, following the model of the genome project in association with specific biomedical, clinical, social and behavioral, and health services delivery research projects. CROSSCUTTING ISSUES Crosscutting issues bridge the disciplines and call for an interdisciplinary approach to their study.
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Study in these areas requires interdisciplinary research that cuts across all of the areas of study clescribed in this report, from basic biomedical to health services delivery. Health Services Delivery Research Significant differences in the utilization of health services by men and women extent]
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In addition, the committee floes not comment on the desirability of increasing expenditures on research on aging versus expenditures on research on children, cancer, AIDS, contraception, the brain, or other major areas of investigation involving health care of younger adults. Although this report is not intendecl to set priorities in the general area of health research, or to set priorities for all health research, the recommendations for additional funding in this section follow from the committee's conviction that increased fundamental research on aging holds the most promise to improve the lives of the ever-increasing numbers of older Americans.
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Funds required to obtain these resources are summarized in Table 2. Additional funds to support the research agenda have not been adjusted for inflation and are to be phased in over a 5year period.
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for the Research Agenda Resource Support Funds Needed Increased NIH funding of research project grants Funding for cooperative clinical trials Non-NIH research support for behavioral/social and health services delivery research Increased support for training of scientists Infrastructure Centers of Excellence Total Construction $ 92 25 80 50 50 15 $312 $1 10 NOTE: Funds are for yearly funding of resources, except for construction funds. Construction funds are a one-time cost.
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House of Representatives has recently advised that the average NIH funding cycle be limited to 4 years, because of the long duration of chronic illness and disability characteristic of aging, the committee urges that more review cycles for research on aging be extended to 5 to 7 years. To increase the funding of approved RPGs on aging, the committee recommends an aciclitional $92 million per year for this purpose, to be phased in over 5 years.
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. The committee recommends that most of the funds for the behavioral and social research and health services delivery research should come from agencies that have traditionally sustained this work E.g., Health Care Financing Administration; Alcohol, Drug Abuse, and Mental Health Administration; and the Agency for Health Care Policy and Research)
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The committee recommends that steps to repair this deficiency include support for 200 additional trainees per year in basic biomedical science. Training in behavioral and social studies and in health services delivery research has Tong been poorly supported {Chapters 4 and 5~.
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The committee believes that the new centers should be interdisciplinary in character, offering opportunities for exchange of ideas and collaboration across the fields of study of basic biomedical science,
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, not adjusted for inflation, the estimated yearly costs of animal colonies at the 10 proposed geriatric research centers are $3.75 million; adding 10 animal colonies at other university centers engaged in gerontological research brings the total cost to $7.5 million per year. Laboratories There are no comprehensive data on the cost of laboratories for basic biomedical and clinical research.
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Using these figures, with the federal government providing 75 percent of the cost of construction, the committee estimates that the total one-time cost for 10 new geriatric research centers will be $75 million, not adjuster! for inflation, phased in over 5 years.
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Table 3 demonstrates the effect of Tow, intermediate, and full funding levels on implementation of the research agenda. For example, funding at 20 percent to 40 percent of the recommended level, phased in over 5 years, would add only about 20 to 40 agerelatec3 research projects per year, or less than 10 percent to the total number of approved and funded research project grants on aging each year.
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(4-5J number per year) Non-NIH support for $16-32 $40-56 $64-80 behavioral/social and health services delivery research Training positions (additional number funded per year)
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A recent IOM workshop recommended that planning be undertaken to explore and implement collaboration between government and industry in biomedical research and education tIOM, 19891. CONCLUDING COMMENTS The committee notes that the community of health science researchers is a great national asset unmatched in number and productivity.
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1983. Active life expectancy.
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1982. Urinary incontinence in elderly nursing home patients.
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