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Extending Life, Enhancing Life: A National Research Agenda on Aging (1991)

Chapter: Executive Summary and Recommendations for Funding

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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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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

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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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:

  1. 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

  2. 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-

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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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

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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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

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
×

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).

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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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),

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
×

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

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
×

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.

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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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-

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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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

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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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

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
×

archival information from previous studies, including data on mortality rates and incidence of disease/disability from different human and animal populations.

  • Add at least 10 Centers of Excellence in Geriatrics and Gerontologic Research and Training (Claude Pepper Centers) to the current three supported by the NIA (see funding section), in which multidisciplinary age-related studies can be carried out and in which high-technology tasks fundamental to a wide variety of research on aging can be supported.

  • 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 yielded new understanding of the physiology of aging, the mechanisms underlying many age-related disorders, the effectiveness of intervention to prevent or treat these disorders, and the characterization of frail elderly people, including those in long-term care. The committee has reviewed this database to identify two major priority areas to serve as the basis for specific research questions and proposals.

These priority areas, described below, overlap in some instances with interests shared by basic biomedicine and other fields of research, including the interest of behavioral/social studies and health services delivery in the study of the effectiveness of intervention in improving the health and function of older persons. This overlap illustrates the interdisciplinary character of age-related research.

Priority Research Recommendations

Research into the causes, prevention, management, and rehabilitation of functional disability in older persons, including a focus on the geriatric syndromes Functional disability in older persons is the major obstacle to independence, and 23 percent of older persons are impaired (less for those under 75; about 50 percent for those 85 and over) in one or more of the self-care activities that make independent existence possible (National Center for Health Statistics, 1985). The clinical research community currently is well positioned to make significant short-term advances leading to improvement in dependency and frailty in persons of advanced old age. This group is increasing rapidly in size and needs help urgently, especially in

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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health promotion and disease prevention, and in studies of specific geriatric syndromes.

Health promotion and disease prevention in old age Although many research areas have been identified, two are offered as examples that show special promise for discovery. First, research should be conducted on the interacting effects of age, lifestyle, and disease on disability among older persons. Intervention studies should determine the changing effect of such factors in the prevention and 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. Obviously, this research is interdisciplinary, overlapping with social and behavioral issues.

Studies of geriatric syndromes Although many syndromes are age associated, the five listed below offer unusually promising opportunities to benefit from careful clinical exploration. These syndromes are among the most prevalent of all late-life maladies.

  • Failure to thrive: This syndrome involves poor nutrition, including decreased appetite and weight loss (often with dehydration), inactivity, depression, impaired immunity, and low cholesterol. One promising line of research is the conduct of crosscohort and longitudinal studies to determine true prevalence, risk factors, and precipitating events of this syndrome. Another important area is the study of interventions to prevent or treat poor nutrition and other factors associated with failure to thrive, such as pressure sores, increased infection, and depression.

  • Impaired postural stability, muscle strength, and mobility: This widespread problem includes falls, dizziness, syncope (fainting), fractures, muscle weakness, and lack of mobility. Each year over one million older persons sustain fractures, including 200,000 hip fractures, that are related to this syndrome (Cummings et al., 1985). Recommended research includes (1) the study of pathophysiologic mechanisms and other factors (e.g., poor nutrition, auditory and visual impairments, and specific neurological defects) underlying recurrent falls and (2) the study of interventions, including drugs, that improve or further impair some of these functions.

  • Mismanagement of medications: Polypharmacy, defined as the taking of three or more medications regularly, occurs in one-third of those over 65. Research in this area should include (1) studies of the fundamental pharmacodynamics of medications in older individuals

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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and (2) studies of medication use and effects that link discoveries in basic biomedicine (e.g., gene delivery systems, specific enzyme-blocking agents, and monoclonal antibodies) to clinical studies, behavioral investigation, and health services research.

  • Urinary incontinence: Although the degree of urinary incontinence varies widely among individuals, this condition is present in approximately 30 percent of community-dwelling older persons (Diokno et al., 1986); 50 percent of those in nursing homes are incontinent (Ouslander et al., 1982). Urinary incontinence has major consequences in suffering and in costs of care among the older population. Behavioral, neuroanatomic, and neurophysiologic studies are needed to determine the basis of urinary incontinence and the efficacy and risk of currently available treatment modalities.

  • Delirium: About one-third of hospitalized elderly individuals develop acute confusion, markedly complicating their hospital course and dramatically increasing morbidity and health care costs (Lipowski, 1989). Very little is known about the predisposing factors, natural history, underlying mechanisms, and effective treatment of delirium.

Studies of the interaction of age-dependent physiologic changes and important diseases in old age Research on the interaction between disease and aging is interdisciplinary, drawing on insights provided by research in molecular biology, physiology, nutrition, and behavioral and social science. This research may prove critical for issues of functional capacity, because the major diseases discussed below impose heavy burdens in old age and because better understanding of the linkage between age-related disease and disability may lead to improved independence in older people.

  • Cardiovascular disorders: Cardiovascular disease is the major cause of death in older persons and is a leading cause of chronic illness and disability. Research should explore genetic and other risk factors as well as the molecular basis of atherosclerosis; the development of standard and recombinant-based drug technologies along with gene therapy approaches and nutritional interventions to treat or prevent hypertension and atherosclerosis; and evaluation over time of therapy for cardiovascular disease to assess cost benefits and effect on quality of life.

  • Dementia and affective disorders: Dementia after age 75 affects 40 percent of the population (Hagnell et al., 1983) and is the major reason for disability among the very old. Great is the need for studies linking basic and clinical approaches to an understanding of the pathophysiology, cause, prevention, and treatment of Alzheimer's disease and other forms of dementia. These studies should include

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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assessment of cellular and molecular markers as well as new approaches to imaging and neurotransmitter mapping of the nervous system. Affective disorders are underreported in old age, although they account for substantial disability (Finlayson and Martin, 1982). Multidisciplinary studies to investigate the pharmacology, neuroendocrinology, and behavioral and social aspects of affective disorders are recommended.

  • Musculoskeletal disorders: Musculoskeletal disorders are second only to cardiovascular disease both as a cause of disability and as a cause of high health care costs among older persons. The application of techniques of powerful reverse genetics such as recombinant fragment length polymorphism (through which genes that contribute to serious genetic disorders such as cystic fibrosis have been found) will help to define the genetic basis of osteoarthritis and osteoporosis in many patients with these common disorders. This approach should receive a high priority as gene replacement techniques are developed as potential cures of such disorders. Other recommended research includes study of nutritional factors and nutritional therapy, and the investigation of the effectiveness of traditional and new rehabilitative interventions on musculoskeletal disorders.

  • Infectious diseases and immunosenescence: Although infection is felt to play an important role in disability in older patients, further study is needed on the contribution of infection to disability and on the effect of prevention and treatment of infection in the older population. Further examples of research include topics such as whether vaccines can bypass the need for immune T cells and whether vaccines made with live attenuated organisms, vaccines with antiidiotypic antibodies, or vaccines with antigens attached to a rigid molecular backbone are effective in elderly persons. Efforts should utilize such new technologies as genetically engineered vaccines and attenuated viruses in studies in this important area.

  • Neoplasia (cancer): Death from cancer is increasing among older persons; indeed, cancer is the second leading cause of lost years of life in the geriatric population. Although accumulation of mutations with age plays a major role in the emergence of neoplasia, more knowledge is needed to explain why age is the most important predictor of cancer in this group; nor is there sufficient information about the value of prevention and treatment of cancer in older patients. Reverse genetics (as described above), recombinant DNA products, and delivery systems using gene transfer approaches (mechanisms for inserting DNA into the body) should be especially valuable in this area. Finally, research into nutritional and other risk factors in the development of cancer should be expanded.

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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  • Disorders of metabolism and homeostasis: Disorders of metabolism and homeostasis may precede and almost always influence the emergence and severity of the conditions described previously. The committee recommends studies on the pathophysiology and molecular genetics of conditions such as diabetes mellitus, altered muscle metabolism, altered bone and mineral metabolism, and altered lipid metabolism in old age.

Additional Research Opportunities

These include:

  • investigation of the molecular biology, pathophysiology, prevention, and treatment of common sensory deficiencies of old age, especially impairment of hearing and vision;

  • examination of the factors associated with oral and dental problems of old age, including periodontal disease, disorders of salivation, and oral-facial pain;

  • study of common skin conditions of elderly persons, such as dry skin, itching, and predisposition to cancers of the skin; and

  • study of the interaction between nutrition and normal aging and between nutrition and age-associated diseases.

Resource Recommendations

The support required for an effective research program in the priority research areas involves added funds, phased in over 5 years, most importantly an increase in the funding rate of NIH-approved investigator-initiated research grants on aging from one in four to one in two; provision of education and support for an additional 200 to 300 fellows and postdoctoral students and 100 to 150 junior faculty per year, coupled with necessary continued support for midlevel investigators new to the fields of geriatrics and gerontology; expansion of current infrastructure supports; and the addition of at least 10 new Claude Pepper Centers, as described more fully in the section on funding.

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 and behavioral interventions. Studies employing such interventions as training in cognitive skills or increasing the sense of competence

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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and self-efficiency in some older individuals who are deficient in these qualities have had dramatic effects on function and health.

Research in the social and behavioral sciences has emphasized that aging is an interactive and lifelong process. This view also has provoked interest in the associations among biological differences, behavior and psychosocial processes, and alterations in physiological systems in health and disease.

The potential of the aging process to respond to modification provides a unique opportunity for future research. Individuals arrive at the end of life by quite different socially determined, as well as biologically determined, routes. Differentiation in older adults provides some of the best evidence for the modifiability of aging processes and the experience of aging. Differentiation refers to variability in aging, both within and across societies. Studies have found that behavioral capacities are multidirectional over the adult life course: some remain stable, and others decline or improve. 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. Cultural and psychological processes influence the aging process in varied and consequential ways. Most studies documenting this influence have focused on reducing agerelated decrements in health. Research is needed to specify the broader areas and limits of the modifiability of aging, emphasizing the enhancement of existing skills and the potential for learning new skills in later life.

Another major perspective in social and behavioral research focuses on the interaction between person and environment. Specific sociocultural contexts influence the aging process differently in specific individuals. Study of these contexts should include how aging differs across societies and across cultural, racial, and ethnic groups; how aging is influenced by differences in work place, treatment environment, living arrangements, and other material and social supports; and how individual capacity and social milieu affect behavior and health outcome.

Priority Research Recommendations

Three research priorities emerge from these themes.

Investigation of the basic social and psychological processes of aging, including specific mechanisms underlying the interrelation

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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ships among social, psychological, and behavioral variables and between these variables and biological aging functions, should be undertaken Examples include investigation of the relationship between memory function and central nervous system structures such as between the hippocampus and cerebellum (Berger et al., 1986), and research on stress-related environmental, psychological, and hormonal factors that lead to anatomic changes in the brain (see cerebral atrophy following extreme stress: Jensen et al., 1982; Finch, 1987). Special attention should be paid to at-risk populations, such as women, the poor, and minorities, since study of these populations may lead to new understanding of the dynamic interaction between biological and social variables.

The relationship between brain and behavior represents an exciting new research frontier. Basic research is needed to provide a clearer understanding of individual differences in sensory, cognitive, and behavioral aging, particularly as these differences reflect relationships between brain and behavior, environment and behavior, and society and behavior. 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 paid to behavioral and social interventions to reduce disability and provide new strategies for management. Research should address rehabilitative strategies, evaluate the social and emotional barriers to rehabilitation, and explore issues related to compliance.

Research that addresses issues of change in population, dynamics, and particularly the question of postponed morbidity is a further high priority Descriptive demography, epidemiology, and population estimates are especially important to forecast the number of older people who will be independent or not. New measures are needed to evaluate the sequence of disease and/or disabling impairment and death for individuals and social groups—compared by cohort over time. Research on the postponement of disability and dependence through changes in social context, and through behavioral intervention, must accompany studies of psychosocial predictors of health, longevity, and functional disability in the aged.

Psychological and behavioral variables may not only contribute to biological aging, but may also serve to mirror physiological dysfunction. In developed societies most older people are vigorous and independent, but certain groups of older adults (e.g., women and minorities) are at higher risk for poverty, social isolation, underemployment, inadequate education, illness, and inaccessibility to health

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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care. Factors that postpone morbidity may function differently in these groups, making them especially important to study.

Research should be undertaken to study the manner in which societal structures and societal changes affect aging Just as individuals change, so too do social structures. Societal old age today shows neither what old age was like in the past nor what it will be like in the future. It is crucial to determine how stability and change in social structures such as the family and work place affect the performance, productivity, health, and quality of life of older adults. Retirement from work or major changes in family structure or in family roles such as the increased entry of women into the workforce provide an opportunity to study how social change affects the experience of aging and health and the well-being of older persons. Research should examine the implication of these changes for social support and caregiving.

Research is needed as well to specify what changes in social structure could improve productivity in older people. Changes in mandatory retirement laws urgently call for more understanding of productivity and psychological processes in older workers. Finally, a life-course perspective should be adopted that views younger adults as the older adults of the future. If children and younger adults who are underemployed, undereducated, and underinsured can be identified and helped, this may improve the well-being of the older population of the future.

Studies derived from the priority research areas identified above may involve large-scale, longitudinal investigations. At the same time, consideration should be given to exploring the use of small-sample studies to enhance our knowledge on key aspects of the aging process.

Additional 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

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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factors among subpopulations for whom the index is low (e.g., the very old and minorities).

Opportunities for behavioral research include the following:

  • study of the psychological concomitants of illness and how these affect self-care and response to formal care;

  • study of the comparative effectiveness of different modalities in the treatment of chronic mental disorders; and

  • examination of the effect of behavioral and social intervention on the outcome of long-term illness.

Resource Recommendations

Despite increases in the federal commitment to health research, the social and behavioral sciences have lost ground relative to other areas of investigation. Support for behavioral and social research on aging in 1989 was estimated at $80–$100 million from the federal government and $10–$15 million from nonfederal sources such as foundations (Behavioral and Social Research Program, NIA). Estimates of resources for the research agenda primarily involve investigator-originated studies and are to be phased in over a 5-year period.

Behavioral and social research will require substantial added 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 and the Alcohol, Drug Abuse, and Mental Health Administration), support for research on aging by non-NIH agencies should be increased by at least 50 percent.

Other support includes training for 200 more behavioral and social scientists per year, one-time costs for construction of additional centers for multidisciplinary research (see the recommendations for funding section), and a share in funds for infrastructure utilized by all areas of research on aging.

Health Services Delivery Research

The growth of the older population, particularly those 85 and over, the chaotic state of today's health care system, rising health care costs, and mounting public concern about value received for the health care dollar lend urgency to the need for a new impetus in health services delivery research. Research in health services delivery expands knowledge about the organization, financing, and deliv-

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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ery of health care services—the path that connects older persons to the benefits of basic biomedical science, clinical studies, and behavioral. and social research.

Major problems and issues of health services delivery for older persons include:

  • continuity of care and long-term care, especially the uneven distribution of services and financing for older persons and the ill-defined relationship between acute and chronic care;

  • drug therapy, especially inappropriate prescribing of medications; poor compliance; and unappreciated alterations in pharmacokinetics and pharmacodynamics in older patients;

  • mental health services, particularly underutilization of mental health services by older people, and the needs of mentally ill elderly persons in nursing home settings; and

  • disability/disease prevention and health promotion services, most importantly the lack of information about the distribution of specific risk factors and the effectiveness of risk reduction programs in older persons.

Priority Research Recommendations

Research in the area of long-term care and continuity of care Research in long-term care and continuity of care should examine cost effectiveness of care; factors determining the need for and utilization of care; the organization and delivery of care (including the special role of the family); the adaptation of technology to foster independence of older persons; caregiving institutions (hospitals, nursing facilities, and other sites); factors determining the locus of patient care; and factors influencing the recruitment, training, retention, and quality of providers of formal and informal long-term care.

The costs and financing of long-term care Research is recommended on existing barriers to care of older persons, the requisite financial elements of insurance programs to support long-term care, mental health services, rehabilitation, and disease prevention and health promotion.

Studies of drug use Investigations should examine factors that influence the development of drugs and the regulatory approval of drugs; the efficacy and efficiency of prescribing, dispensing, and taking of pharmaceuticals; inappropriate drug therapy; interventions to maximize drug treatment; and examination of drug-related phenomena affecting social and physical functioning.

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Mental health services research This research should be expanded to identify the determinants of the need for and use of mental health services, the role of treatment as a factor in improving social and physical functioning, and the effect of earlier psychiatric intervention on reducing later-life disability and health care costs.

Research in the fields of disability/disease prevention and health promotion There is a major need to develop new models for the delivery of appropriate behavior change programs for elderly populations.

Additional Research Opportunities

These include:

  • study of alternative methods of delivering long-term care, including models that focus on a particular subgroup (e.g., posthospital management) and that link housing arrangements with community long-term facilities;

  • examination of the effect of employer-initiated cost-sharing on the use of preventive and treatment services;

  • study of the effectiveness of case-management compared with other methods of delivering and organizing health care;

  • research on the provision of mental health services to elderly institutionalized persons in the context of need, utility, and outcome;

  • investigation to compare the relative contribution of accepted risk factors in the development of disease among young and aged populations; and

  • research into the effectiveness of new technologies, including information technologies (computers) and robotics, in the delivery of health care.

Resource Recommendations

To implement the health services delivery research program the committee recommends additional funds to (1) 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) train an additional 140 investigators per year in the health services delivery field, and (3) increase databases and meet infrastructure needs. Health services delivery research will also participate in the 10 new multidisciplinary research and training centers (see the funding section), and in shared

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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infrastructure funding. Because significant funding for health services delivery studies comes from outside NIH, additional funds are requested from agencies traditionally supporting this research (e.g., the Health Care Financing Administration and the Agency for Health Care Policy and Research).

Research in Biomedical Ethics

Ethical issues accompany all aspects of health care of older persons and are at the heart of research on this group. Areas of major importance in ethics and in the study of aging include the following: dilemmas regarding life-sustaining treatment, selection of therapeutic interventions based on age, distribution of health care resources, and the need to include older subjects in research. Prolonging life in some patients may not (or may) be desired by them or be appropriate; guidelines to establish, responsibility for these decisions often are problematic for elderly persons. Competing social needs, growing costs of care, and the enlarging population of sick and disabled older persons pose problems of resource allocation that require agreement on how to make such determinations fairly. 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 life-sustaining treatment

Allocations of health care resources

Participation in clinical research by frail elderly persons

Additional Research Opportunities

These opportunities include:

  • study of clinician-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;

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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  • defining appropriate care standards for elderly persons;

  • investigation of the use of age as a criterion for allocation of health services;

  • study of ethics in day-to-day interaction between caregivers and older patients (e.g., autonomy of older patients); and

  • research into the trade-off between quality of care and quality of life for older patients.

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. Such issues include gender, ethnic origin, cultural background, ethics, race, and the interdisciplinary approach to training and scientific investigation.

Basic Biomedical Research

Major crosscutting issues here involve the study of the effect of race, gender, ethnic background, and other factors on the trajectory of aging, ranging from the cellular level to the intact organism. This study involves coordinated efforts with other disciplines to provide an integrated approach to multifactorial phenomena. The overarching issue of ethics applies to basic biomedical investigation in raising questions about the care and disposition of experimental animals and the application of new discoveries, such as gene transplants. Finally, interdisciplinary education in the area of gerontology/geriatrics should be supported.

Clinical Research

Clinical research on aging engages many disciplines. Insights from molecular and cell biology provide a basic biomedical foundation for

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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much clinical research. Behavioral and social research along with health care delivery studies can facilitate clinical investigation of the response of older people to illness and of the effect of interventions to reduce disability and morbidity occurring late in life.

Of equal importance are crosscutting issues that involve gender, racial, and ethnic differences in response to illness, including how older persons experience illness, or in the metabolic disposition of drugs. It would be interesting to understand, for example, the marked difference in morbidity of blacks compared to whites with equal degrees of hypertension or of women compared to men insofar as hypertension-related morbidity is concerned. Another issue involves ethics in clinical research—a subject discussed in the previous section of this summary.

Behavioral and Social Research

Many crosscutting issues arise in behavioral and social research, including the effects of gender, race, and ethnicity on longevity, functional status, and morbidity in old age; social role expectations and appropriateness of intervention; and population dynamics to predict longevity and morbidity. In addition, neurobiological study of cognitive defects will be enriched by combination with approaches to intellectual function and its modifiability through behavioral and social intervention. Study in these areas requires interdisciplinary research that cuts across all of the areas of study described 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 extend beyond the distribution of chronic illnesses and morbidity in these groups. Gender differences are seen in participation in programs of prevention and in economic/social status of older persons. These variances should be investigated further. Other topics include the assessment of need for health services based on different patterns of illness and disability between men and women, gender influence on response to different modes of health care delivery, and sex differences in utility of common preventive and risk reduction interventions.

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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RECOMMENDATIONS FOR FUNDING THE RESEARCH AGENDA ON AGING

The committee believes that a major investment in research on aging is needed urgently and therefore recommends additional funds of about $312 million per year, not adjusted for inflation, phased in over a 5-year period. These funds, added to current research supports of approximately $601 million, total $913 million annually, a figure approaching the $1 billion recommended by the Pepper Commission (1990). In addition, a nonrecurring expenditure on construction of about $110 million will be required. Programs of research on aging and support for centers should continue to be funded on the basis of merit and the accepted high standards of competition for research funds.

To estimate added funds for the study of aging the committee used available data (e.g., costs for centers, research projects, and training); where substantiating evidence was limited, the committee's decisions were based on judgment.

The federal government bears most of the cost of health care for older persons and is the only institution with the resources and organization to provide the wide-ranging research support requested in this report. Foundations and industry will add to support for research on aging, but it is mainly to the federal government, especially for its support of NIH and other federal department and agency sponsored research on aging, that the committee's recommendations are directed.

It should be noted that in estimating funds for age-related research the committee did not consider the effects of a large increase in spending on research on aging on other U.S. health and human welfare-related research, and the committee realizes that resources are not unlimited. In addition, the committee does 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 intended 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.

Table 1 summarizes the National Research Agenda on Aging. The additional resources required to develop this agenda include research project grants, centers for the study of aging, funds for infrastructure, construction for centers and infrastructure, and training of new

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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TABLE 1 National Research Agenda on Aging: Summary of Research Priorities

Research Area

Research Priorities

Basic biomedical research

Abnormal cell proliferation

The aging brain

Clinical research

Functional impairment and disability

Interaction of age-dependent physiological changes and disease

Behavioral and social research

Interaction of social, psychological, and biological factors in aging

Changes in population dynamics; the postponement of morbidity

Changes in societal structures and aging

Health services delivery research

Long-term care and continuity of care

Costs and financing of long-term care

Medications and older persons

Mental health services

Disability and disease prevention and health promotion

Biomedical ethics

Dilemmas involving life-sustaining treatment

Allocation of health care resources

Participation of older persons in research

SOURCE: Institute of Medicine, 1991.

investigators. 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 5-year period.

Derivation of Recommendations for Funding
Funds for Research Projects

Major achievements in the health sciences are rarely predictable, but have usually come from the laboratories of gifted investigators exploring basic research questions. These advances often require the support of research originating from individual researchers or from small groups of investigators. Therefore, the preeminent expansion

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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TABLE 2 Summary of Additional Funds (rounded off in millions of dollars) Needed for the Research Agenda

Resource Support

Funds Needed

Increased NIH funding of research project grants

$ 92

Funding for cooperative clinical trials

25

Non-NIH research support for behavioral/social and health services delivery research

80

Increased support for training of scientists

50

Infrastructure

50

Centers of Excellence

15

Total

$312

Construction

$110

of support for the research agenda on aging must be a major increase in funding for approved age-related research project grants (RPGs), especially the traditional investigator-initiated proposals (R01s) by the NIA and other branches of the NIH.

NOTE: Funds are for yearly funding of resources, except for construction funds. Construction funds are a one-time cost. All estimates are in current dollars.

In fiscal year 1990 the average funding of approved RPGs at the NIH was 25 percent (4,917/18,956); at the NIA funding of approved RPGs was 24 percent (192/799) (Office of Information Systems Branch, Division of Research Grants, National Institutes of Health). The percentage of funding for approved RPGs is slightly lowered by the presence of reapplications. For example, in fiscal year 1990 at the NIA 30 percent of the approved RPG applications (241/799) were resubmissions. The NIA funding rate for approved reapplications was 23 percent (55/241), and for first-time applications was 25 percent (137/558); the lower rate of funding of reapplications slightly diminished the overall funding rate of approved RPGs to 24 percent. A similar small effect of reapplications on the percentage of funding of approved RPGs was seen for the total number of RPGs funded by the NIH.

To improve support for this most important source of discoveries in aging, the committee recommends that funding of approved RPGs

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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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)

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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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

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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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.

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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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,

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
×

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).

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
×

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

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
×

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-

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
×

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

Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
×

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.

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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Suggested Citation:"Executive Summary and Recommendations for Funding." Institute of Medicine. 1991. Extending Life, Enhancing Life: A National Research Agenda on Aging. Washington, DC: The National Academies Press. doi: 10.17226/1632.
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Next: 1. Introduction »
Extending Life, Enhancing Life: A National Research Agenda on Aging Get This Book
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Americans are living longer than ever before. For many, though, these extra years have become a bitter gift, marred by dementia, disability, and loss of independence.

Extending Life, Enhancing Life sets the course toward practical solutions to these problems by specifying 15 research priorities in five key areas of investigation:

  • Basic biomedicine—To understand the fundamental processes of aging.
  • Clinical—To intervene against common disabilities and maladies of older persons.
  • Behavioral and social—To build on past successes with behavioral and social interventions.
  • Health services delivery—To seek answers to the troubling issues of insufficient delivery of health care in the face of increasing health care costs.
  • Biomedical ethics—To clarify underlying ethical guidelines about life and death decisions.

Most important, the volume firmly establishes the connection between research and its beneficial results for the quality of life for older persons.

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