Executive Summary and Recommendations for Funding

Science offers the best hope to improve the older person's quality of life. Research that is directed and supported properly can provide the means to reduce disability and dependence in old age, and can decrease the burdens on a health care system strained to its limits.

This is a time for celebration but a time as well for deep concern. 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 advanced old age. It is a time for concern because, for a growing number of older people and their families, these added years of life often are burdened by disability, dementia, and the loss of independence.

In testimony before the Committee on a National Research Agenda on Aging, Joseph A. Califano, former Secretary of Health, Education, and Welfare, said:

The aging of America will challenge all our political, retirement, and social service systems. As never before, it will test our commitment to decent human values. Nowhere is the aging of America freighted with more risk and opportunity than in the area of health care.

The urgent need to respond to this risk is underscored by census figures showing that the subgroup of older persons most vulnerable to disability and dementia, those 85 years of age and over, is growing six times faster than the rest of the population, and by evidence indicating that the cost of caring for disabled older persons will more



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Extending Life, Enhancing Life: A National Research Agenda on Aging Executive Summary and Recommendations for Funding Science offers the best hope to improve the older person's quality of life. Research that is directed and supported properly can provide the means to reduce disability and dependence in old age, and can decrease the burdens on a health care system strained to its limits. This is a time for celebration but a time as well for deep concern. 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 advanced old age. It is a time for concern because, for a growing number of older people and their families, these added years of life often are burdened by disability, dementia, and the loss of independence. In testimony before the Committee on a National Research Agenda on Aging, Joseph A. Califano, former Secretary of Health, Education, and Welfare, said: The aging of America will challenge all our political, retirement, and social service systems. As never before, it will test our commitment to decent human values. Nowhere is the aging of America freighted with more risk and opportunity than in the area of health care. The urgent need to respond to this risk is underscored by census figures showing that the subgroup of older persons most vulnerable to disability and dementia, those 85 years of age and over, is growing six times faster than the rest of the population, and by evidence indicating that the cost of caring for disabled older persons will more

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Extending Life, Enhancing Life: A National Research Agenda on Aging than double in the coming decades unless the causes of disability can be identified and controlled (Schneider and Guralnick, 1990). The following themes of risk and opportunity have guided the preparation of this report, and have justified support for the study of aging through scholarship and research: the need to control acute and chronic illness in old age and to achieve a major reduction in disability and suffering, thus not merely extending life but enhancing it; and the new opportunity offered by science to improve the quality of life for older persons through analysis and discovery of the relationships among basic biological phenomena, disease, economic and social deprivation, disability, and dependence. Building on two reports by the National Institute on Aging (NIA), Our Future Selves (1978), and Toward an Independent Old Age: A National Plan for Research on Aging (1982), 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 biomedical ethics. To this end, the Institute of Medicine (IOM) convened a committee of 18 leaders in national health care, and charged them to: identify for the next two decades priorities in research on aging that will contribute to the quality of life and maximize the independence of older persons; stimulate research on the fundamental processes of aging and the prevention of disability and disease, and further the application of current knowledge to the treatment of age-related disorders; alert scientists to promising but neglected areas of research on aging; provide the stimulus that will encourage new investigators to undertake the study of aging, and continue to engage the interest of established researchers in this field; estimate the resources required to fulfill the scientific needs for gerontological and geriatric research; guide federal and nonfederal funding agencies in supporting this research, and identify collaborative and nonduplicative funding patterns for government, industry, and private sources of support; and bring the importance of research on aging to the attention of government, private institutions, industry, the scientific community, and the public at large. During the project the committee became convinced of the impor-

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Extending Life, Enhancing Life: A National Research Agenda on Aging tance of ethical issues in clinical care and research on aging, and added this topic to the agenda. Four liaison teams aided 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. Recommendations on biomedical ethics were provided by two national authorities in this field. The reports of the liaison teams (see Appendix B) served as a major resource for the committee's deliberations. Guidance also was provided by five senior advisors who have made major contributions to the field of health care. Lastly, advice from experts in private foundations, government, industry, national organizations, and scientific institutions was obtained. The report, although assisted by information provided by more than 150 authorities, is the product of the committee's critical analysis of information received and represents the independent decisions of the committee. Committee members and liaison team leaders developed criteria to identify priority research topics. Although different fields of study emphasized different criteria, in general, priority research areas were selected for their potential to: contribute to the understanding of the basic mechanisms of aging; address problems of disability and functional impairment in older persons; increase knowledge both of the interaction between disease and aging and of age-related diseases; lower morbidity and mortality rates among older persons; be implemented in a timely and feasible manner, with short-term goals achievable in 5 years or less and long-term goals achievable in 5 to 20 years; lead to cost reduction in health care; increase knowledge of behavioral and social factors in health and disease, and help older people maintain social as well as biological health; improve pharmacologic treatments of patients; and attend to relatively neglected areas of investigation. The 1982 Toward an Independent Old Age: A National Plan for Research on Aging lists more than 350 research possibilities; the present committee 's agenda is restricted to 15 areas of priority research. As conceived, the research priorities listed in this report represent the conceptual issues that underlie the questions and specific propositions of research proposals. The committee notes

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Extending Life, Enhancing Life: A National Research Agenda on Aging that in developing research priorities all five of the research areas were felt to be of first-rank importance, and the committee emphasizes that support should extend across all five of the fields of age-related research described in this report. Within each field of research, priorities are ranked according to their importance to the understanding of aging and their potential to improve the quality of life for older persons. A national research agenda on aging has a broad multidisciplinary view, but it must be selective. The charge by the IOM dictated an agenda with the most promise for substantial impact on the individual during the next two decades—that is, research on the health and functioning of older individuals. BACKGROUND Support for Training and Research in Geriatrics and Gerontology At the heart of health care for the older 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. A 1980 study predicted that by the year 1990 training would be needed to produce 7,000 to 10,300 geriatricians to provide care for older persons having the most complex geriatric problems—those 75 years of age and over (Kane et al., 1980). Programs for training have not met this goal, as shown by the finding that by the mid-1990s there will be only 5,000 certified geriatricians in this country (Reuben et al., 1990). To train an adequate number of geriatricians, Kane et al. (1980) estimated a fulltime geriatric faculty of 1,230 to supervise hospital training programs in internal medicine or family practice, plus 370 to staff medical schools, and 450 for geropsychiatry, totaling about 2,100 faculty members and comprising both academic clinicians and researchers. A 1987 IOM study, commenting on the small number of geriatric training programs (under 5 percent of all postgraduate medical programs), found that these programs graduated about 100 fellows per year and recommended that to meet needs for biomedical faculty by the year 2000 the number of graduates per year should be raised to at least 200 (IOM, 1987). Another study found training programs far short of goals for the year 2000 to develop nonbiomedical (mainly behavioral and social scientists) faculty in aging (National Institute on Aging, 1987). The serious shortage of faculty and researchers in

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Extending Life, Enhancing Life: A National Research Agenda on Aging age-related fields requires prompt attention by organizations that have traditionally supported this training (National Institute on Aging; Department of Veterans Affairs; National Institute of Mental Health). Although training programs on aging, initially supported by the National Institute of Mental Health and the National Institute of Child Health and Human Development, began in the 1950s and 1960s, the establishment of the National Institute on Aging, the development of research and training programs in aging by the Department of Veterans Affairs, and the growth of scores of university programs in this country have taken, place for the most part since 1970. Many discoveries in aging arising from this national effort—from molecular biology to behavioral and social science—await application to health problems and to improvement of function in older people. Support is needed to continue these advances. The 1990 budget of the National Institutes of Health (NIH) devoted about $442 million, or about 6 percent of all funds, to the study of aging, with about $239 million coming from the NIA (including funds for research grants, centers, education, and demonstration projects) and an additional $203 million for research on aging coming from other parts of the NIH (Office of Planning, Technology, Information, and Evaluation, NIA). In 1990 other federal departments and agencies (see Chapter 7 for details) provided additional funds of about $144 million for research on aging. Foundations added $15 million in support. The National Pharmaceutical Association lists $3.6 billion for research and development on drugs used to treat diseases occurring in older patients, but it is difficult to know how much of this money was designated for age-related research as such. An increase in funding for research on aging could produce rapid advances in the ability to respond to the problems of many older persons. For example, the neurosciences are poised to make major discoveries in Alzheimer's disease, but for every 100 dollars spent on care for the victims of this disease, under 0.5 percent, or less than 50 cents, goes to research that might lead to the control of Alzheimer's disease (Advisory Panel on Alzheimer's Disease, 1989). A recent article underscored the effect of restricted funds on research, noting that at the NIA the funding rate of approved traditional investigator-initiated research projects (R01s) for fiscal year 1989 was 16.9 percent, or about one in six (Movsesian, 1990). 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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Extending Life, Enhancing Life: A National Research Agenda on Aging Low funding rates for research grants diminish opportunities for developing careers in age-related studies and may contribute to undersubscription to training programs in geriatrics (IOM, 1987). In 1990 support for research on aging from all sources (NIH + Department of Veterans Affairs + other federal departments and agencies + foundations), described further in Chapter 7, amounted to an estimated $601 million, or less than 0.5 percent of the estimated 1987 (the most recent year for which figures are available) $162 billion cost of care for disability and illness in older patients (Waldo et al., 1989). This small national commitment to research in aging is a wasteful strategy in light of the potential contribution of research to improve the status of older persons and to reduce the enormous and expanding costs of their care. A growing sense of urgency is accompanied by the recognition that the time is right to bridge the gap between the needs of an aging society and the scientific knowledge base. The nation now needs a comprehensive plan for research on aging. By identifying research priorities and the resources to support research on aging, it is the committee's intent to respond to that need. The Aging Society: Current Costs for Health Care of Older Persons Most older persons are vigorous and have lives of good quality, and more than 50 percent of those 80 years and over are independent in self-care. 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 had risen in recent years (Rice, 1989). Of the 10 leading causes of death among older persons, only 2—heart disease and diabetes mellitus—are listed among the 10 leading chronic geriatric conditions (National Center for Health Statistics, 1989). Most of the leading chronic conditions involve disability and prolonged decline. Disability here is defined as any restriction on or impairment in performing an activity in the manner or within the range considered normal for a human being (World Health Organization, 1982). Chronic conditions contributing to disability include arthritis, heart disease, strokes, disorders of vision and hearing, nutritional deficiencies, and oral-dental problems (in up to 40 percent of older persons; Baum, 1988). Dementia (especially Alzheimer's disease),

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Extending Life, Enhancing Life: A National Research Agenda on Aging not listed as a leading cause of death or disability in older persons, nevertheless for those 75 years and older is a major contributor to disability, nursing home placement, and, indirectly, to mortality rates (Weiler, 1987). Fewer than 7 percent of persons aged 65 to 74 require assistance with dressing or bathing. At 75 to 84, these activities require help in 7 percent to 14 percent of older persons, and at 85 and beyond, up to 30 percent will need help with bathing (National Center for Health Statistics, 1987). Nursing home placement is needed 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 (ADLs: bathing, dressing, grooming, transferring from bed to chair, going to the bathroom, being continent, feeding oneself), but for every one of the 1.4 million in skilled nursing facilities, two equally impaired older adults are receiving care at home. The cost of health care for older persons is great and growing rapidly. In 1987 the cost to provide health care for elderly patients was $162 billion or $5,360 per capita, compared with $45.2 billion ($1,856 per capita) a decade earlier (Waldo et al., 1989). Medicare costs alone were almost $75 billion for the care of disability and illness among old people in 1987, and they may rise to $145 billion per year (in 1987 dollars) by the year 2020 (Schneider and Guralnick, 1990). Sick older people are burdened by accelerating costs for their own care. In 1980 the average yearly expenditure by older persons for health care was $966, and in 1988 it was $2,394. Costs for medical care borne by older people have more than doubled in the past decade and may triple in the coming decade (Select Committee on Aging, 1990). The Potential of Research on Aging The description of the compression of morbidity in old age (Fries, 1980), with the older person collapsing suddenly after many years of vigor, has stimulated a closer study of the relationship between morbidity and mortality in old age. In 1986 a 65-year-old person could look forward to 17 more years of life and an 85-year-old to 6 more years. By contrast, active life expectancy, which implies ability to care for oneself and be independent, was only 10 years for 65 to 70-year-olds, and for 85-year-olds it was only 2.9 years (Katz et al., 1983). Diminishing mortality rates thus may swell the ranks of sick and

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Extending Life, Enhancing Life: A National Research Agenda on Aging debilitated elderly persons, and the number of years of dependent old age may increase, with ever greater outlays for health and medical care (Gruenberg, 1977; Schneider and Guralnick, 1990). Like Tithonus, to whom the god Zeus gave eternal life without eternal youth (Graves, 1955), long life is a punishment if the quality of the later years is poor. A model developed by Manton describes the potential of intervention to improve the quality of life for older persons. If medical care fails to diminish the incidence of disease among older persons, therapy that reduces lethal complications of disease may increase life expectancy in this group, but at the high cost of prolonging chronic illness and associated disability. Therefore, basic research should aim to promote interventions that decrease mortality by diminishing the incidence, severity, and rate of progression of disease. This approach will then improve active life expectancy as well as life expectancy, with slowing of the rate of “aging,” and with increased independence among older individuals (Manton and Soldo, 1985; Soldo and Manton, 1988; Fries, 1990). An example of this kind of intervention is seen in the recent advances in the prevention and treatment of the chronic degenerative disorder osteoporosis, and related hip fractures in older women. The power of research to reduce health costs dramatically usually is underestimated. The lifetime cost to maintain two Rh brain-damaged children or two children severely crippled by poliomyelitis (and there were thousands of these children in 1960) was greater than all of the money spent on the research that virtually eliminated these conditions (J. Krevans, University of California, San Francisco, personal communication, 1990). Postponing by one month the onset of severe disability that leads to nursing home placement for older persons could lead to savings of $3 billion per year, minus the cost of providing care for these patients at home. This is based on 1987 figures (the most recent available) for nursing home costs of $32.8 billion per year for those 65 years of age and over (Waldo et al., 1989), adjusted for inflation to $36 billion for 1990. The committee is convinced that basic research, properly supported and directed, holds the promise to decrease chronic illness and disability in old age, enriching the quality of life and maintaining vigor and independence in the later years.

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Extending Life, Enhancing Life: A National Research Agenda on Aging A NATIONAL RESEARCH AGENDA ON AGING Basic Biomedical Research While the term aging can apply to changes occurring during any phase of life, dysfunctional aging (or senescence) refers to changes associated with accelerated morbidity and mortality rates during the latter phase of adult life. Biomedical studies on the disorders of senescence include not only specific disease states but also conditions not easily classified. Basic biomedical science can substantially improve the quality of life for older persons, and add to the list of social and medical advances in which the nation takes pride, advances that eliminated so many of the killing and crippling diseases of childhood and younger adults. A number of puzzling questions about aging have attracted the interest of biomedical researchers. Why do humans differ so individually in aging changes of bone, brain, and heart? What preconditions for aging may be set earlier in life, perhaps even in utero? What is the role of gene-environmental interactions in the individual patterns of aging? The committee believes that understanding these processes will lead to interventions that may delay or even reverse disability. Although many fundamental processes of aging are yet to be understood, progress already has been made in distinguishing between the process of natural aging and disease states associated with older age. Achieving further knowledge will require contributions from genetics, biochemistry, cell biology, neurobiology, and other disciplines. Equally important is the integration of aging research with other areas of investigation that historically have focused on specific organs and diseases without considering the surrounding manifold of aging changes. The committee emphasizes that many major advances in science have been unanticipated. Therefore, it is essential to maintain the traditional primacy of investigator-initiated studies—the source of many research breakthroughs. Recent advances in the basic biomedical study of aging will contribute significantly to the foundation for future progress in the understanding of how individuals age. Among these achievements are insights into gene regulation and other basic cellular functions; the development of colonies of rats that have shown increased lifespan and delayed decline of function following food restriction; and the creation of strains of mice with targeted mutations (i.e., basic changes in the genetic blueprint for proteins) that will improve understanding of the processes of aging. Major conceptual and methodological successes in molecular biol-

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Extending Life, Enhancing Life: A National Research Agenda on Aging ogy will lead to high-resolution gene mapping and to increased understanding of gene expression at the molecular level. These advances have the potential for identifying the location and cloning of genes responsible for various age-related disorders, including familial Alzheimer' s disease. It will then be possible to study how such genes may be controlled to prevent or further delay the adverse effects of age-related disorders. The elucidation of the biological mechanisms of aging and the clinical and lifestyle interventions derived from these discoveries will improve the quality of advanced age. Moreover, such research findings are eminently achievable. Priority Research Recommendations For the 1990s and the first decade of the twenty-first century, planning and implementation of a multiinstitutional basic biomedical research effort in two principal areas should be undertaken. Abnormal cell proliferation Research in this area involves the study of proliferative homeostasis, a fundamental process responsible for the orderly replacement of cells lost because of either exposure to toxins or endogenous processes (Martin, 1979). Mechanisms underlying pervasive disturbances in proliferative homeostasis that accompany aging in humans and other mammals are pivotal in many diseases that cause senescence. Alterations in cell replacement are vital to regeneration and repair, but they contribute to the genesis of many forms of cancer, atherosclerosis, osteoarthritis, benign prostatic hyperplasia, and disturbed immune function. The committee proposes that this major new national initiative be comparable in emphasis to the number one priority of the NIA—Alzheimer's disease and the neurobiology of aging. Brain aging Basic research in the neurosciences (including the peripheral and central nervous systems) and the current special research initiatives on Alzheimer's disease should be continued and expanded. Additional Research Opportunities The research priorities in basic biomedical science listed above merit primary consideration for implementation, but other promising areas of biogerontological investigation, discussed at length in

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Extending Life, Enhancing Life: A National Research Agenda on Aging Chapter 2, also merit support. Some of these important research directions are as follows: the study of the repair and regeneration of postmitotic nondividing cells, including neurons and cardiac and skeletal muscle cells, as well as conditionally proliferating cells, such as hepatocytes; the study of the major integrative systems of physiology, including the effects of aging on the immune and endocrine-neuroendocrine systems, the effect of dietary restriction on lifespan, and the regulation of reproductive and developmental physiology; the study of the varying rates of aging among different cells, tissues, and organs for individual differences within species and for species differences that will provide information about genetic influences; the study of the biomarkers of aging, their relationship to overall functional state, and the role of functional capacity as a marker of senescence; the study of the general question of gene expression in aging (especially as applied to the abnormal proteins associated with Alzheimer's disease or the inactivation of enzymes with age), selective changes in gene activity, and the effects of environmental influences on aging (e.g., free radicals, radiation, and various toxins); and the use of comparative genetics and development of new model systems to study aging and the lifespan. 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. Increase the availability of animal models (including primates and other long-lived animals that more closely resemble humans) and laboratory animal models with contrasting maximal lifespans. Improve access to cell lines and tissue samples, especially cryopreserved cells and tissues, and cell and tissue types from different human populations that crosscut age, sex, and stages of disease (e.g., different stages of diabetes mellitus or Alzheimer's disease). Expand existing human longitudinal studies, making available

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Extending Life, Enhancing Life: A National Research Agenda on Aging in aging by the NIA and other divisions of the NIH should be increased from the current level of one in four to one in two. In addition, although the U.S. 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 additional $92 million per year for this purpose, to be phased in over 5 years. The committee suggests that a significant part of this increase should be made available as soon as possible in order to take advantage of high-quality projects ready for implementation and also to provide early encouragement to scientists interested in entering the field of studies on aging. The increase in funding applies to RPGs at the NIA and to RPGs on aging approved by other branches of the NIH. In fiscal year 1990 NIA support for 192 RPGs (at $190,000 per RPG) was $36.5 million, or about 17 percent of the total NIA budget of $239 million (Budget Office, NIA). The percentage of funds devoted to RPGs at the NIA was higher than the overall 12 percent ($945 million/$7.6 billion) of the total NIH budget funding of all RPGs for fiscal year 1990 (Division of Research Grants; Reports, Analysis, and Presentation Section, NIH). The committee was unable to obtain information about the number of non-NIA-funded RPGs on aging, but estimated a minimum number of about 294 RPGs. This estimate was based on an average cost of $190,000 per RPG per year and assignment to age-related RPGs of 30 percent, or $55.8 million, of the $186 million committed to research on aging by non-NIA institutes in fiscal year 1990 (see Table 7-1). This is a conservative estimate: the actual funding and number of these non-NIA RPGs may have been higher because the non-NIA institutes committed fewer dollars to training and other non-research project supports of studies on aging than did the NIA. Given the estimate of non-NIA support for RPGs on aging, the figure of about $92 million in additional funds can derived from the following calculations: Funding of approved RPGs on aging: funding level—one in four • NIA $36.5 million (192 RPGs) • NIH $55.8 million (294 RPGs) • Total $92.3 million (486 RPGs)

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Extending Life, Enhancing Life: A National Research Agenda on Aging Funding of approved RPGs on aging: funding level—one in two • NIA $36.5 million × 2 = $73 million (384 RPGs) $36.5 million additional funding (192 added RPGs) • NIH $55.8 million × 2 = $111.6 million (588 RPGs) $55.8 million additional funding (294 added RPGs) • Total $92.3 million additional funding (486 added RPGs) These figures are estimates and may require revision as the new agenda on research is implemented. Because a significant percentage of RPG proposals represents resubmissions that were previously approved but not funded, the new funding rate for approved grants may have variable effects on the eventual number of approved grants that are reviewed for funding. Increasing the funding of approved research grants on aging should reduce the number of resubmissions that are reviewed for funding, but this trend will be offset if more investigators are encouraged by the new funding rate to resubmit grant proposals that were approved but not funded in the past. Therefore, the committee recommends that the target for funding of approved RPGs be set at one in two, subject to review and modification as the new program to expand research on aging is implemented. Funds for age-related research sponsored by the NIA and other institutes most often support biomedical research proposals, although some funds also support research on aging in health services delivery and in social and behavioral studies. As Chapter 4 and Chapter 5 emphasize, these areas have been chronically underfunded for many years. For example, an estimated fewer than 20 percent of approved research proposals on aging in behavioral and social research are funded each year (Behavioral and Social Program, NIA). 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), and that the new funds should total at least $80 million per year in current dollars. The 1991 NIA appropriation funds 381 RPGs (Budget Office, NIA). This new support is in concert with the committee's recommendation for increased funding of RPGs on aging, and should be extended to RPGs on aging throughout the NIH. There is information that other federal institutions may also increase their support for age-related research in the coming fiscal year. Funding for an additional five cooperative studies on prevention, demography, epidemiology and treatment of age-related disorders is

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Extending Life, Enhancing Life: A National Research Agenda on Aging recommended by the committee. These studies would implement research priorities identified earlier, and should be phased in over a 5-year period. Cooperative studies require about $5 million per study for support in current dollars (Director's Office, NIA), totaling $25 million dollars at full implementation Funds for Training in Age-Related Studies A recent IOM study recommended that the number of graduates in medical academic geriatric programs be increased from its current level of 100 per year to 200 to 250 per year to meet the estimated 2,100 biomedical faculty members needed in this field by the year 2000 (IOM, 1987; Rowe et al., 1987). Additional funds should be phased in over a 5-year period to implement this recommendation. Assuming that training programs for clinical investigators last 2 to 3 years, this would involve support for an additional 200 to 300 fellows in training at all levels. In addition, funds should be provided for 100 to 150 beginning clinical investigators in research on aging. Because training programs in age-related research are currently undersubscribed, it may be best to phase in major support for training programs after it has been shown that the increased investment in research has attracted more students to the field. The committee believes that the current cadre of faculty members with interests in age-related research is adequate to provide initial training for increased numbers of students in this area. The NIA estimated in 1987 that the number of trainees in age-related studies, including clinical and basic biomedical research on aging, was far short of the number needed to meet present needs (NIA, 1987). 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 long been poorly supported (Chapters 4 and Chapter 5). In a 1987 report to Congress, the NIA predicted that more than 1,500 nonbiomedical faculty, including behavioral and social scientists, would be needed by 1990 for teaching and research needs in the field of aging, and that more than 3,500 such professionals would be needed by the year 2000 (NIA, 1987). The report noted that by 1987 only a small percentage of the 1990 training needs had been met. The committee 's recommendations provide for an additional 200 doctoral trainees per year in behavioral and social studies in aging, and 140 additional trainees per year in health services delivery research.

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Extending Life, Enhancing Life: A National Research Agenda on Aging Acknowledging that there are differences in stipends, benefits, and faculty support, depending on the level of training and the discipline involved, the committee judges that the added training across the areas of study will involve stipends, benefits, and faculty support at an average cost of $50,000 per trainee. The total number of additional trainees recommended is about 1,000, and the cost—not adjusted for inflation—for this training is $50 million per year, phased in over 5 years. Funds for Centers The committee recommends that funds should be phased in over the next 5 years for 10 Centers of Excellence in Research and Teaching in Geriatrics and Gerontology (Claude Pepper Centers) to be added to the current 3 NIA-sponsored Centers of Excellence. Although the value of the centers has been questioned, and there is no clear understanding of the number of centers needed, arguments for interdisciplinary centers on aging have been given in a recent IOM report (IOM, 1987), and by the 1984 Department of Health and Human Services report on education and training in geriatrics and gerontology. According to these reports, during the early phases of the evolution of the study of aging, centers can (1) serve to mobilize and focus scarce resources, (2) provide a setting for growth of new investigators, and (3) enhance creative interaction among scientists in diverse areas of research on aging (IOM, 1987). To merit support for the development of a Center of Excellence, “a program must meet three central goals: 1) to develop a structured, efficient training program that will attract students and produce faculty; 2) to conduct research to add to clinical knowledge, maintain an academic base, and provide role models for trainees; and 3) provide clinical care in a variety of settings. . . .” (IOM, 1987). If these goals are met and if the presence of a cadre of investigators and teachers (whose research efforts are already well supported) can be demonstrated, then a university or medical center may qualify for center support. The NIA currently supports three centers. Four additional Centers of Excellence have been approved, but not funded, and six other sites are under consideration for development. Review of applications received by the NIA indicates that sufficient faculty numbers now exist to provide the necessary professional staffing of these proposed centers (Office of the Director, NIA). 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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Extending Life, Enhancing Life: A National Research Agenda on Aging clinical research, behavioral and social studies, health services delivery, and biomedical ethics. Estimation of the cost of the new centers is based on outlays for the Claude Pepper Geriatric Centers. These institutions required about $1.2 million per year for support (Office of Geriatrics Branch, Biomedical Research and Clinical Medicine Program, NIA). Based on this information, the 10 additional centers should cost about $12 to $15 million per year to operate (not adjusted for inflation). Funding of the new centers goes largely toward administration costs, for infrastructure costs, and toward other supports, such as salaries for beginning investigators. Direct funds for research would not depend on center support, but would come rather from grants to individual investigators and to research programs operating within the centers. Funds for Infrastructure Factors that make it difficult to assign costs for infrastructure research support to the different areas of research include the use of animal colonies by several disciplines for research, overlap of funds for research and infrastructure, development of databases that all disciplines may draw upon, and uncertainty in classifying new linkages to existing sources of information. Given these constraints, the committee offers the following estimates for infrastructure costs. Animal colonies Based on the cost in the Pepper Centers of $375,000 per animal colony per year (Office of Geriatrics Branch, Biomedical Research and Clinical Medicine Program, NIA), 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. Apart from laboratories at centers, funds are necessary to support noncenter laboratory needs in age-related basic biomedical and clinical research in other institutions. For example, three sophisticated laboratories for cell biology research to serve as regional resources for basic biomedical and clinical scientists would cost $3 million per year to staff and maintain (G.M. Martin, University of Washington, personal communication, 1989).

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Extending Life, Enhancing Life: A National Research Agenda on Aging Databases This important infrastructure will be shared by all disciplines and consists of ongoing population studies, improved linkage to existing sources of information (e.g., Medicare data tapes), library supports such as the National Library of Medicine, and computer technology. Research in geriatrics and gerontology will require the expansion of existing population studies (e.g., National Health and Nutrition Examination Survey) and the institution of new longitudinal demographic and epidemiological studies. The cost of such studies covers a wide range, from $1.5 million to $2.0 million per year (Office of the Director, NIA) for the Health and Retirement Study funded by the NIA, to $5 to $10 million per year (G.M. Martin, University of Washington, personal communication, 1989) for large cardiovascular prospective studies. The committee estimates that population studies would come to about $30 million per year. Another $10 million per year, shared among the disciplines, would be needed to add computer technology, to fund improved access to existing databases, and to increase the capacity of reference sources such as the National Library of Medicine. All told, the estimated nonassigned infrastructure support totals $40 million per year. Total costs for infrastructure, not adjusted for inflation, are estimated at $50.5 million per year, phased in over 5 years. Funds for Construction Construction costs include those for 10 additional multidisciplinary centers and those for out-of-center animal facilities and laboratories. The cost of construction of the Mental Retardation Research Centers supported by the National Institute of Child Health and Human Development was, on average, $10 million per center; the federal government provided 75 percent of the funding, and local and state organizations made up the difference. 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 adjusted for inflation, phased in over 5 years. Center costs include animal housing. Additional animal housing will cost $300 to $400 per square foot (Office of Resources Development, NIA). If 10 animal facilities are built outside the centers, and if total floor space at each of these additional institutions comes to 1,000 square feet (assuming an average of 5 separate projects at each institution), total costs will be about $3.5 million. Costs to construct new laboratories, based on

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Extending Life, Enhancing Life: A National Research Agenda on Aging the committee's best estimate, are assessed at an additional $30 million, not adjusted for inflation. The committee therefore estimates that the total one-time costs for construction, not adjusted for inflation, will be about $110 million; as described above, these costs are to be phased in over a 5-year period, with $33 million of this sum assigned to construction of infrastructure supports distributed among several areas of research. Table 3 demonstrates the effect of low, 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 age-related research projects per year, or less than 10 percent to the total number of approved and funded research project grants on aging each year. Support for trainees over 5 years at this level would add only 40 to 80 trainees per year, or 4 percent to 8 percent per year of the additional number needed. To implement research on aging in the coming decade, funding levels for resources should approach or equal the recommended total of $312 million per year, plus construction monies. Recommendations for funding outlined in this section were based, as far as possible, on known costs for construction, infrastructure, grant support, research centers, and training. Determination of funding needs will require further examination and review prior to implementation of the new research agenda. The estimates given here represent a first step in this process. IMPLICATIONS FOR FUNDING AGENCIES Support for the research agenda can come from many sources. The committee suggests the following: Federal agency support: Support by the federal government has been detailed in the section describing funding requirements for research. As noted, large-scale projects require federal support. Additionally, the federal government should provide research funds for research in biomedical ethics. Early in this effort, the NIA and/or other agencies should convene a national conference to determine the need for support, levels of funding, and ways of implementing the research agenda on biomedical ethics. Private and corporate foundations: The increased flexibility of foundations makes them better able to support innovative research programs—both basic and applied—with relatively short-term goals. It would also be appropriate for foundations to join in supporting fellowships to train scientists for age-related research and to partici-

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Extending Life, Enhancing Life: A National Research Agenda on Aging TABLE 3 Scenarios of Partial (Low, Medium, and High) Support for Aging Research Scenarios (in millions of dollars) Research Support Low Medium High Total yearly funds (% of recommended) $62-115 (20-37%) $156-215 (50-69%) $250-312 (80-100%) NIH support for RPGs (additional number per year) $18-37 (97-194) $46-64 (243-340) $74-92 (389-486) Cooperative clinical trials (additional number per year) $5 (1) $10-15 (2-3) $20-25 (4-5) Non-NIH support for behavioral/social and health services delivery research $16-32 $40-56 $64-80 Training positions (additional number funded per year) $10-20 (200-400) $25-35 (500-700) $40-50 (800-1000) Centers of Excellence (additional number funded) $3-6 (2-4) $7-10 (5-7) $12-15 (8-10) Infrastructure $10-20 $25-35 $40-50 Construction $22-44 $55-80 $88-110 NOTE: Totals may not equal sums of columns because of rounding off. Funds are for yearly funding of resources, except for construction funds. Construction funds are a one-time cost. All estimates are in current dollars. pate in the funding of geriatric research centers. Foundations can further support research in geriatrics and gerontology by funding national conferences to plan for research and dissemination of research findings or by funding training programs such as the Brookdale Foundation support of the NIA Summer Training Institute for young researchers. Industry support: Resources to support new technologies, evaluate

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Extending Life, Enhancing Life: A National Research Agenda on Aging new drug therapy, and develop educational programs could be provided by industry sources. Combined support: Government, foundations, and industry could combine resources for nationwide policy conferences on age-related research, support for fellowships, development of geriatric research centers, and creation of functions to facilitate communication about studies in aging among different institutions. A recent IOM workshop recommended that planning be undertaken to explore and implement collaboration between government and industry in biomedical research and education (IOM, 1989). CONCLUDING COMMENTS The committee notes that the community of health science researchers is a great national asset—unmatched in number and productivity. Moreover, the cadre of scientists working in aging has increased rapidly throughout the country over the last 10 years and provides a major resource for new advances in basic and applied research. Prospects are bright for the application of new knowledge in the service of improved social, psychological, and physical health for older persons, for those who will reach old age in the near future, and especially for those who are now young. The numerous areas of basic and applied research in aging presently led by U.S. scientists also are a foundation for major innovation and application in the private sector. There is great potential for new drugs and consumer goods adapted to the special needs of older persons; the world market for them is growing rapidly. Moreover, the principles of genetic engineering already exist not only for organ repair and replacement but also for control of the adverse effects of inherited genes. Thus, the goals of this 20-year plan for research point to a unique U.S. role in meeting the needs of the older population throughout the world. REFERENCES Advisory Panel on Alzheimer's Disease. 1989. Report of the Advisory Panel on Alzheimer's Disease. DHHS Pub. No. (ADM) 89-1644. Washington, D.C.: U.S. Government Printing Office. Baum, B. J. 1988. Oral cavity. Pp. 157-166 in Geriatric Medicine, J. W. Rowe and R. W. Besdine, eds. Boston: Little, Brown. Berger, T. W., S. D. Berry, and R. F. Thompson. 1986. Role of the hippocampus in classical conditioning of aversive and appetitive behaviors. Pp. 203-239 in The Hippocampus, vol. 4, R. L. Isaacson and K. H. Pribam, eds. New York: Plenum. Cummings, S. R., J. L. Kelsey, M. C. Nevitt, and K. J. O'Dowd. 1985. Epidemiology of osteoporosis and osteoporotic fractures. Epidemiology Review 7: 178-190.

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