7

Review of Resources Committed to Research on Aging

It is difficult to identify the resources committed to research on aging. The limitations on measuring resources include the following: self-reporting by researchers; the absence of biologic markers to identify the research territory of old age; shared study targets, as in the examination of disorders found at several stages of life (e.g., diabetes, atherosclerosis, hypertension); the inclusion of administrative and training costs in research budgets; and the fact that basic discoveries in almost any area of biological science may contribute to the quality of life of older persons.

Despite these limitations, estimates of current support and future needs for research on aging are needed in order to promote realistic planning for this expanding area of study.

FUNDING SUPPORT FOR RESEARCH ON AGING

The Federal Government
National Institutes of Health

Most federal support comes from the National Institutes of Health (NIH). In fiscal year 1990, funds committed to the study of basic biomedical aspects of aging were about $442 million, or 5.8 percent of all NIH research funds, with $239 million coming from the National Institute on Aging (NIA) (Office of Planning, Technology,



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Extending Life, Enhancing Life: A National Research Agenda on Aging 7 Review of Resources Committed to Research on Aging It is difficult to identify the resources committed to research on aging. The limitations on measuring resources include the following: self-reporting by researchers; the absence of biologic markers to identify the research territory of old age; shared study targets, as in the examination of disorders found at several stages of life (e.g., diabetes, atherosclerosis, hypertension); the inclusion of administrative and training costs in research budgets; and the fact that basic discoveries in almost any area of biological science may contribute to the quality of life of older persons. Despite these limitations, estimates of current support and future needs for research on aging are needed in order to promote realistic planning for this expanding area of study. FUNDING SUPPORT FOR RESEARCH ON AGING The Federal Government National Institutes of Health Most federal support comes from the National Institutes of Health (NIH). In fiscal year 1990, funds committed to the study of basic biomedical aspects of aging were about $442 million, or 5.8 percent of all NIH research funds, with $239 million coming from the National Institute on Aging (NIA) (Office of Planning, Technology,

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Extending Life, Enhancing Life: A National Research Agenda on Aging Information and Evaluation, NIA). Table 7-1 summarizes funds for research on aging as reported by the institutes. Department of Veterans Affairs Veterans 65 and older constituted 27 percent of the veteran population in 1990, and this figure is expected to rise to 37 percent by the year 2000. The Department of Veterans Affairs (DVA) has been a leader in the development of research and training in geriatrics and gerontology in this country. In fiscal year 1990 the DVA reported about $17 million for age-related research, or 8.5 percent of the 1990 research budget of $201 million for the Department of Medicine and Surgery (Office of Assistant Chief Medical Director for Research and Development, DVA). Alcohol, Drug Abuse, and Mental Health Administration In fiscal year 1990 the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) spent $42 million on research on aging, including $38 million on age-related research by the National Institute of Mental Health, or 4.9 percent of its total research budget of $855 million (Division of Financial Management, ADAMHA). Health Care Financing Administration The Health Care Financing Administration (HCFA) is the overseeing federal agency for Medicare and Medicaid, and in fiscal year 1990 it committed approximately $40 million to age-related studies, or about 82 percent of its research budget of $49 million for that year, largely in health services delivery (Office of Research and Demonstrations, HCFA). Most of this support was for demonstration projects; although demonstration projects can contribute to an understanding of aging, the committee believes that these funds cannot entirely be credited to support of research on aging. Agency for Health Care Policy and Research The Agency for Health Care Policy and Research (AHCPR) (formerly the National Center for Health Services Research and Health Care) spent $19 million on research on aging, or about 20 percent of its research budget of $95 million in fiscal year 1990 (Office of Financial Management, AHCPR). Most of the research supported was directed to the area of health services delivery.

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Extending Life, Enhancing Life: A National Research Agenda on Aging TABLE 7-1 National Institutes of Health (NIH Support for Research on Aging (in thousands of dollars) Institute a 1989 1990 1991 (estimated) National Institute on Aging (100) $ 222,545 $ 238,927 $ 323,752 National Cancer Institute (1.1) 16,531 14,499 15,467 National Heart, Lung, and Blood Institute (2.1) 22,240 19,585 20,600 National Institute of Diabetes and Digestive Disorders (2.5) 14,127 20,800 21,700 National Institute of General Medical Sciences b National Institute of Neurological Disorders and Stroke (6.9) 33,141 35,920 45,975 National Institute of Allergy and Infectious Diseases (3.8) 28,506 32,998 35,678 National Eye Institute (13.4) 31,077 34,878 36,273 National Institute of Environmental Health Sciences (2.3) 1,696 1,917 1,997 National Institute of Arthritis and Musculoskeletal and Skin Disorders (8.4) 13,590 13,995 15,744 National Institute of Deafness and Communicative Disorders (16.5) 1,511 7,947 9,007 National Center for Research Resources (2.8) 9,995 7,487 7,293 National Center for Nursing Research (11.3) 3,295 6,651 8,000 National Institute of Dental Research (4.2) 5,483 5,785 6,437 Office of Director (0.6) 461 400 400 Subtotal/aging $ 404,198 $ 441,789 $ 548,323 (% of total budget) (5.7%) (5.8%) (6.4%) Total NIH budget $7,152,207 $7,576,537 $8,511,782 a Numbers in parentheses are the percentage of the unit's 1989 budget allocated to research on aging. b No support for research on aging identified. SOURCE: Office of Planning, Technology, Information and Evaluation,NIA

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Extending Life, Enhancing Life: A National Research Agenda on Aging Other Federal Departments and Agencies Other agencies that provided support for research on aging included the Department of Agriculture, which committed $23 million in fiscal year 1990 for studies of nutrition in older persons (Office of Budget and Management Staff; Agriculture Research Service), and the Administration on Aging, which devoted about $3.0 million to research on aging that largely involved social and behavioral studies (Division of Research and Demonstrations) for the same year. Industry and Foundations Industry Industry support for research on aging is difficult to measure because there is no central information repository. Indirect evidence comes from a review of the literature (see below), which showed that 5 percent of research papers on aging cited corporate support. A special case of research support by industry is that of the pharmaceutical companies. In 1989, U.S. companies spent more than $3.6 billion on research and development of drugs primarily used to treat diseases that afflict older patients (Pharmaceutical Manufacturers Association). This was 50 percent of the pharmaceutical industry's total research and development budget of $7.3 billion for the year. Cardiovascular disorders (stroke, heart disease, and hypertension) consumed 39 percent of the reported age-related research budget; the remainder of the budget supported investigation of drugs for the treatment of cancer, arthritis, and other conditions that afflict the geriatric population. Because most of these disorders also affect younger persons and because a significant portion of the funds went for development purposes, one cannot state with certainty how much of these funds actually supported age-related research. Foundations Information on foundation support for research on aging was obtained from the Foundation Center's 1989 publication Grants for the Aged and from a computer search of the center's on-line Grants Index. Both sources report information about corporate and foundation contributions of $5,000 or more. The Foundation Center reports that, from 1986 to early 1987, 2.5 percent of the monies given by private and corporate foundations were directed to the general area of aging, and less than 1 percent of all foundation philanthropy was for

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Extending Life, Enhancing Life: A National Research Agenda on Aging age-related research. In 1989, about $59 million was given for general projects in aging; of this sum, about $15 million (25 percent of all funds for projects in aging) went for studies specifically devoted to research on aging. The balance supported services, education, and administrative support for age-related programs. Foundations providing major support for research on aging included the Commonwealth Fund, New York; the Charles A. Dana Foundation, New York; the John A. Hartford Foundation, New York; the Henry J. Kaiser Family Foundation, California; the John D. and Catherine T. MacArthur Foundation, Illinois; the Robert Wood Johnson Foundation, New Jersey; the Weingart Foundation, California; and the Pew Charitable Trusts, Pennsylvania. Information about state and local support of age-related research is difficult to obtain. A few states, such as California (through the statewide Academic Geriatric Research and Education Program) provide limited funds to support studies on aging. Local (city and county) support for research on aging could not be estimated because of the absence of any central source for such information. INSTITUTIONS ENGAGED IN RESEARCH ON AGING Centers for Research on Aging Supported by the NIA Centers for the Study of Alzheimer's Disease The NIA has established centers for basic science and clinical studies in Alzheimer's disease at the following institutions: Baylor College of Medicine, Texas Case Western Reserve University, Ohio Columbia University, New York Duke University, North Carolina Harvard University, Massachusetts Mount Sinai School of Medicine, New York Johns Hopkins University, Maryland University of California at San Diego University of Kentucky University of Michigan University of Pittsburgh, Pennsylvania University of Southern California University of Texas Southwestern Medical Center University of Washington Washington University (St. Louis), Missouri

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Extending Life, Enhancing Life: A National Research Agenda on Aging Centers of Excellence in Research and Teaching in Geriatrics and Gerontology (Claude Pepper Centers) Three Claude Pepper centers have been funded by the NIA. The NIA also provides funds for research in numerous university-based research centers through program project grants (P01). However, it is not always possible to characterize the centers receiving such funds as primarily age-oriented in their research activities. Geriatric Research, Education, and Clinical Centers of the Department of Veterans Affairs There are 7 million veterans 65 years old or older; half of all men in this country who are 65 and older are veterans. By the year 2000 there will be 9 million veterans 65 and over; 4 million of these will be 75 and over. In response to the needs of the veteran population the Geriatric Research, Education, and Clinical Centers (GRECC) program was initiated by act of Congress in 1975, and was expanded by further legislation in 1980. There are now 13 GRECCs, with 3 more planned for fiscal year 1991. Their purpose is to integrate basic research, teaching, and clinical achievements. Research activities of these centers are summarized in Table 7-2. Teaching and Research Nursing Homes The Robert Wood Johnson Foundation has sponsored eight teaching and research nursing homes affiliated with university medical schools. Research activities at these institutions are summarized in Table 7-3. Other Institutional Supports for the Study of Aging A noteworthy step by the private sector towards recruitment for careers in geriatrics took place in 1988, as the John A. Hartford Foundation initiated a strategy of supporting centers of excellence. The program, enhanced and broadened during 1989, encourages medical students and practicing physicians at 10 sites across the United States to specialize in academic geriatrics. Although there are dozens of university centers for the study of aging across the country (including biomedical, behavioral and social, and health services delivery programs), a 1987 review of medical school-based fellowships in geriatrics identified only 13, at that time, as having an adequate complement of research and teaching personnel and implementing a full research program in aging (Institute of Medicine, 1987).

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Extending Life, Enhancing Life: A National Research Agenda on Aging TABLE 7-2 DVA Geriatric Research, Education, and Clinical Centers Location Research Activities Ann Arbor, Mich. Neurosciences; metabolic and endocrine factors; autonomic function in diabetes mellitus and hypertension Bedford, Mass. Neurobiology of aging; immunology; rheumatology; computer-based clinical evaluation Brockton-West Roxbury, Mass. Influence of normal aging on homeostatic mechanisms: cardiovascular, endocrine, and neuroendocrine; carbohydrate metabolism Durham, N.C. Cancer and cardiovascular disease in aging; research on physical fitness Gainesville, Fla. Geropharmacology; molecular biology of aging; gene expression and aging; nutrition; neoplasms Little Rock, Ark. General basic and clinical research; role of antioxidants; motor and cognitive deficits Minneapolis, Minn. Study of Parkinson's disease; Alzheimer's disease Palo Alto, Calif. Endocrinology; metabolism; age-related changes in cognition; approaches to health delivery; depression San Antonio, Tex. Metabolism; endocrinology; nutrition; oral health and dentistry Seattle, Wash. Age-related changes in behavior and neuroendocrine function, and their relationship to health services Sepulveda, Calif. Endocrinology; memory; health services delivery St. Louis, Mo. General basic and clinical oncology; hypertension; gastroenterology; infectious disease; nephrology West Los Angeles, Calif. Basic science and clinical study of immunology; osteoporosis; evaluation of health care SOURCE: DVA Department of Medicine and Surgery. Office of Geriatrics and Extended Care, Washington, D.C. PUBLICATIONS ON RESEARCH IN AGING The scientific literature represents an important resource for all future research activities. In order to estimate changes in the knowledge base and to identify trends in research activity in geriatrics and gerontology, the Institute for Scientific Information (ISI) undertook a screen of 500,000 articles from 1983 to 1987. Funding supports and

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Extending Life, Enhancing Life: A National Research Agenda on Aging TABLE 7-3 Areas of Study at Teaching and Research Nursing Homes Institution Research Activities University of California, San Diego Nosocomial infections; predictors of institutionalization; sleep apnea Yeshiva University Dementia; osteoarthritis; motor control impairment; age-associated memory failure; congestive heart failure Harvard University Syncope and altered blood pressure; homeostasis in the elderly; urinary incontinence; vitamin D physiology and nutrition; risk of institutionalization; Alzheimer's disease: depression, neuroendocrine function Case Western Reserve University Respiratory and gastrointestinal infections; immune processes and tuberculosis; visual perception and Alzheimer's disease; neuroendocrine function in Alzheimer's disease Johns Hopkins University Metabolic regulation; cardiopulmonary physiology; sleep physiology; neuropsychological function University of Pennsylvania Urinary tract infection; regional cerebral structure and function in dementia; sleep apnea Stanford University Modifiable factors influencing health status/health care; hormones and hip fractures; cognitive function in diabetics; care in nursing homes University of Iowa Parkinson's disease; chronic conditions involving functional or cognitive impairment; interaction of stress and social supports institutions of origin of scientific papers in 1982, 1983, and 1987 were assessed by ISI and by King Research, Inc., at the request of the Institute of Medicine. In 1983, about 4,900 papers (or 1.7 percent of the total file of scientific reports) focused on aging; by 1987 the number of age-related research reports had risen to 8,900 (2.7 percent of the total file). The total file increased by 9 percent during this interval, resulting in an absolute increase in published studies on aging of 70 percent. Major areas of growth in the literature were in the neurosciences, including Alzheimer's disease, neurologic aging, cognition/ memory, and Parkinson's disease. Reports in the area of neurological function and Alzheimer's disease increased fourfold. Second in

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Extending Life, Enhancing Life: A National Research Agenda on Aging growth were reports on infectious disease and osteoporosis in the aged. Social and psychological studies, health services delivery research, and pharmacology were well represented in both years, showing a modest increase in the number of publications between 1983 and 1987. Examination of the social and behavioral literature showed a high level of interest in geriatrics in 1983, but no striking change in the rate of publication was noted in the subsequent four years. A further observation by the ISI review was that the increase in studies on aging involved many clearly defined areas of geriatric interest (e.g., studies of geriatric syndromes) with contributions made by many different fields of research (internal medicine, neurology, molecular biology, sociology, psychology). This observation demonstrates both the wide interest in the investigation of aging and the emergence of a body of information and research techniques that is focused on age-related topics. Until recently, as the ISI findings indicated, aging studies not reported in publications clearly identified as focused on aging have tended to appear in professional journals devoted to behavioral and social science or to health services delivery research, with few reports appearing in medical and other scientific publications. That this trend has changed is illustrated, if not proven, by the increase between 1983 and 1987 in age-related studies reported in the selected medical and scientific journals shown in Table 7-4. Although these peer-reviewed journals showed a more than 150 percent increase in publication of articles on research in aging between 1983 and 1987, further study is necessary to establish the presence of a significant trend. Of interest is the quadrupling of articles on aging in the neurology literature. During the period 1983 to 1987 there was also a significant increase in the number of journals devoted to the study of aging. No support was listed for 16 percent of papers on age-related research in 1987; presumably, this support was provided by the institution of affiliation of the investigators. Among remaining papers, citations of support were divided as follows: government, 45 percent; foundations, 30 percent; foreign sources, 20 percent; and corporations, 5 percent. PERSONNEL ENGAGED IN THE STUDY OF AGING A 1980 study indicated that 7,000 to 10,300 geriatricians would be needed by the year 1990 (Kane et al., 1980). Based on staffing of 3 to 5 full-time faculty per teaching hospital and medical school, the

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Extending Life, Enhancing Life: A National Research Agenda on Aging TABLE 7-4 Number of Age-Related Publications in Selected Journals Journal 1983 1987 American Journal of Medicine 9 28 American Journal of Physiology 9 16 American Journal of Public Health 8 21 Annals of Internal Medicine 21 42 Annals of Neurology 17 54 Archives of Neurology 10 62 Brain Research 35 156 British Medical Journal 38 40 Journal of Clinical Investigation 5 9 Journal of Clinical Psychiatry 8 12 Journal of Comparative Neurology 20 72 Journal of Experimental Psychology 1 12 Journal of Neurochemistry 11 48 Journal of Neurology, Neuroscience and Psychiatry 12 41 Journal of Neuroscience 7 43 Journal of the American Medical Association 38 49 Lancet 36 56 Neurology 18 80 Neuropsychology 2 13 Neuroscience Letters 16 63 New England Journal of Medicine 31 65 Proceedings, National Academy of Sciences 9 40 Science 13 32 Social Science and Medicine 3 23 Total 377 1,077 SOURCE: Institute for Scientific Information, Philadelphia, Pa. study predicted a need for 2,100 biomedical faculty to provide training for these geriatricians. It has been estimated that, by the year 2000, in order to meet the medical needs of the expanding older population, 10,000 to 21,000 geriatricians will be needed, and 14,000 to 29,000 will be needed by the year 2020 (NIA, 1988). Training of these physicians will require a major increase in staffing of departments of medicine and family practice by researchers and teachers with special competence in geriatrics and gerontology. In 1987 the Institute of Medicine reported that only 100 geriatric fellows were graduating per year from hospital-based medical school programs. The report estimated that to meet requirements for an estimated 2,100 faculty by the year 2000 to train future clinicians and biomedical students of aging, the number of graduating fellows

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Extending Life, Enhancing Life: A National Research Agenda on Aging should be increased by at least 100 percent (Institute of Medicine, 1987). A report to Congress from the NIA (1988) and a study from the University of California at Los Angeles (Reuben, personal communication, 1990) support this recommendation. Although a recent report (Reuben et al., 1990) indicates that despite a recent upsurge in interest in geriatrics by internists and family practitioners, with as many as 5,000 certified geriatricians in practice by the mid-1990s, this is far short of the estimated minimum of 10,000 required by that time to provide adequate care of the older population. A survey in 1986 of 400 graduates of geriatric biomedical fellowship programs showed that two-thirds held academic positions, but only 35 percent of those surveyed committed more than 10 percent of their time to teaching and research (Siu et al., 1989). The study pointed to a low rate of publication (1.3 papers per graduate annually) among the recent graduates compared with fellowship graduates in other disciplines, and it concluded that the goal of producing academic geriatricians is far from being met. Thus, given even the most generous estimate of biomedical personnel engaged in research on aging, fewer than 150 graduates of fellowship programs in geriatrics spend more than 10 percent of their time in research. Balancing this estimate of the small number of researchers engaged in studies of aging is the observation that 15,047 authors were listed in geriatric and gerontological publications (including behavioral and health services research studies) in 1987, an increase of 34 percent over 1982 (King Research, Inc.). While this information cannot be interpreted as indicative of growth in the fulltime complement of research investigators in aging, it points to a significant upward trend in the involvement of academic faculty in gerontologic and geriatric studies. Biomedical age-related research is carried out by faculty M.D.s and biomedical Ph.D.s, with some studies in behavioral aspects of aging done by a small number of physician psychiatrists. The reports on training cited above did not measure the need for scientists and practitioners in behavioral or social studies, or in health services research. As noted in Chapter 4 and Chapter 5, support for training of Ph.D.s and other investigators in behavioral and social research or in health services delivery is inadequate, and the production of teachers and researchers in these fields must be expanded if all of the needs of the older generation are to be met. In a report to Congress (NIA, 1988) the NIA estimated the minimum requirements for faculty, including physicians, for the years 1990 and 2000 (Table 7-5). The estimates included faculty in the areas of psychology, pharmacology, and nursing, but did not include information about faculty to train social

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Extending Life, Enhancing Life: A National Research Agenda on Aging TABLE 7-5 Faculty Needs in Age-Related Studies, 1990 and 2000 Faculty Work Place 1990 2000 Medical schools—physicians 600 1,300 Medical schools—other faculty 600 1,300 Nursing schools 750 1,500 Dental schools 80 120 Social work schools 300 1,000 Optometry schools 80 125 Pharmacy schools 150 300 Clinical psychology schools 150 450 SOURCE: National Institute on Aging (1988). scientists or other nonbiomedical researchers on aging. The estimates, totaling about 2,900 faculty for the year 1990, and about 6,000 for the year 2000, were based on the expectation that 25 percent of physician time and 50 percent of the time of other faculty would be committed to research. A 1987 report stated that the numbers of geriatric and gerontological faculty—including teachers and scientists in the fields of behavioral and social studies, and health services delivery—were inadequate to provide adequate training for health care personnel to meet the medical and nonmedical needs of older persons (NIA, 1988). In fiscal year 1990 the total number of trainees (biomedical; behavioral and social; neuroscience and neuropsychology) supported by the NIA was 425, a figure far short of the number required (Office of Planning, Technology, Information, and Evaluation, NIA). The training of faculty must be increased sharply and as soon as possible if the recommended minimum goal of 6,000 additional faculty (biomedical and nonbiomedical) for research and teaching in age-related studies and the care of older persons is to be reached by the year 2000. REFERENCES Institute of Medicine. 1987. Academic geriatrics for the year 2000. Journal of the American Geriatrics Society 35: 773-791. Kane, R., D. Solomon, J. Beck, E. Keeler, and R. Kane. 1980. The future need for geriatric manpower in the United States. New England Journal of Medicine 302: 1327-1332. National Institute on Aging. 1988. Personnel for Health Needs of the Elderly Through the Year 2020. September 1987 Report to Congress. Document 1988-205-735-736:32533, U.S. Department of Health and Human Services. Washington, D.C.: U.S. Government Printing Office.

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Extending Life, Enhancing Life: A National Research Agenda on Aging Reuben, D. B., T. B. Bradley, J. Zwanziger, J. H. Hirsh, and J. C. Beck. 1990. Candidates for the certificate of added qualifications in geriatric medicine. Who, why and when? Journal of the American Geriatrics Society 38: 483-488. Siu, A. L., G. Y. Ke, and J. C. Beck. 1989. Geriatric medicine in the United States. The current activities of former trainees. Journal of the American Geriatrics Society 37: 272-276.

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