1

Introduction

Over the past two decades the American system of health care and the biomedical, social, and behavioral sciences have begun to come to grips with the overwhelming consequences of the rapid and dramatic growth of the elderly population. Long neglected, the topic of aging has attracted substantial attention as this country seeks to build the infrastructure of a national research and academic capacity in aging. For instance, the National Institute on Aging (NIA) and scores of university and medical school academic programs in gerontology and geriatrics have been established, and recently developed training programs are generating a cadre of sophisticated gerontologists and geriatricians.

In addition to building the foundation for what is becoming one of the nation's major new scientific efforts, recent financial investments in aging have already yielded important research findings across a spectrum of inquiry, including the basic mechanisms of aging, the physiology of normal aging, the social and behavioral aspects of aging, health services research for older persons, and the etiology and management of age-related disease. A bibliometric search, conducted in conjunction with the project that forms the basis of this report, shows that between 1983 and 1987, taking into account overall growth in research, there was a 70 percent relative increase in scholarly publications in aging. Although growth in some of these areas, particularly in age-related disease (e.g., Alzheimer's disease), has clearly outstripped growth in other areas, all domains



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Extending Life, Enhancing Life: A National Research Agenda on Aging 1 Introduction Over the past two decades the American system of health care and the biomedical, social, and behavioral sciences have begun to come to grips with the overwhelming consequences of the rapid and dramatic growth of the elderly population. Long neglected, the topic of aging has attracted substantial attention as this country seeks to build the infrastructure of a national research and academic capacity in aging. For instance, the National Institute on Aging (NIA) and scores of university and medical school academic programs in gerontology and geriatrics have been established, and recently developed training programs are generating a cadre of sophisticated gerontologists and geriatricians. In addition to building the foundation for what is becoming one of the nation's major new scientific efforts, recent financial investments in aging have already yielded important research findings across a spectrum of inquiry, including the basic mechanisms of aging, the physiology of normal aging, the social and behavioral aspects of aging, health services research for older persons, and the etiology and management of age-related disease. A bibliometric search, conducted in conjunction with the project that forms the basis of this report, shows that between 1983 and 1987, taking into account overall growth in research, there was a 70 percent relative increase in scholarly publications in aging. Although growth in some of these areas, particularly in age-related disease (e.g., Alzheimer's disease), has clearly outstripped growth in other areas, all domains

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Extending Life, Enhancing Life: A National Research Agenda on Aging have seen substantial growth from their meager beginnings over four decades ago. Notwithstanding this progress, the medical and scientific community 's knowledge, research, and clinical capacity lag far behind the human need, and society currently is paying a heavy price for decades of neglect of aging and the special needs of older persons. The burgeoning elderly population will increasingly burden the nation's fiscally troubled health care system. Despite our recognition that investments in research ultimately yield substantial financial, clinical, and social benefits, the nation's commitment to aging research is minuscule in comparison to the costs of health care for older persons. Even in the case of Alzheimer's disease—one of the best-supported areas of age-related research—expenditures for scientific investigation equal less than one-half of one percent (0.1 percent) of the costs of care for the victims of this disease (Report of the Advisory Panel on Alzheimer 's Disease 1988-1989, U.S. Department of Health and Human Services, DHHS Pub. No. (ADM)89-1644). Given the heavy toll and long duration of chronic illness and disability, the small national commitment to aging research is a particularly risky and potentially wasteful strategy, especially in light of the enormous promise of properly supported research, not only to improve the status of older adults, but also to reduce substantially the costs of their care. Effective strategies against many disorders common in old age, such as dementia, urinary incontinence, osteoporosis, and falls, could yield huge financial savings and, at the same time, enhance well-being. Likewise, research is needed on intervention strategies to ameliorate the deleterious conditions of economic and social dependency, the growing caregiving burden, and inadequate coping capacities. Such research could reduce negative health effects and their attendant costs while improving the aging experience for millions of Americans. A factor limiting the development of gerontologic and geriatric research is the critical shortage of workers in this area. Current funding mechanisms often do not provide adequate research or training support for young investigators interested in studying aspects of aging. The United States must develop effective mechanisms to attract established scientists from other fields into aging or age-related research, and it must construct attractive career ladders for young investigators from a variety of fields who enter the study of aging as a career. A growing sense of urgency mandates that the time is right to narrow the gap between the needs of an aging society and the scientific knowledge base. Building on the existing academic sub-

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Extending Life, Enhancing Life: A National Research Agenda on Aging strata, the medical and scientific community can leverage both new knowledge and tools from other fields to develop aging research into a mature component of the national scientific portfolio. For example, dramatic recent developments in several fields—from molecular biology to the social sciences—await application to age-related issues and hold the potential of rapidly advancing the nascent fields of gerontology and geriatrics. There is an increasing awareness that the field of aging may be entering a phase of major breakthroughs that have the potential not only of increasing our understanding of age-related diseases and enhancing functions in the elderly but also, quite possibly, of beginning to solve the mystery of the human lifespan. This opportunity is constrained, however, by increasing fiscal pressures. At this critical juncture the nation's needs demand a comprehensive plan for research on aging. This document represents the result of the Institute of Medicine's (IOM's) effort to develop a plan in recognition of this need at the request of a number of federal agencies and foundations. The IOM convened 87 experts from various fields relevant to aging and age-related research in a two-year study to identify the needs and opportunities for research on aging in basic biomedical science, social and behavioral sciences, clinical medicine, health services delivery, and biomedical ethics. The group sought to document and outline recent exciting developments in aging research, to set clear priorities for future research, and to estimate the resources required to enter into such an agenda for the nation's research scientists. A major thrust of this report examines processes of discovery and treatment that will improve function in the elderly population, without denying the importance of research whose focus is restricted to investigation of disease. This study includes three stages. During the first stage, commissioned papers were developed, and a detailed bibliometric analysis of aging research was conducted. In the second stage the expert committee met several times to deliberate and prepare this report. For the report the committee sought input from a wide variety of agencies and organizations interested in or supportive of research on aging. The committee has reviewed the current funding inventory as well as the results of the bibliometric analysis. Liaison teams comprised of experts in the areas of biomedical, clinical, behavioral and social, and health services delivery research were charged with developing a prioritized list of special research opportunities and needs for the next 10 to 20 years. In addition, two national authori-

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Extending Life, Enhancing Life: A National Research Agenda on Aging ties in the field of biomedical ethics provided information about research needs in this area. After reviewing and discussing the reports of the liaison teams and ethicists, the committee sculpted the overall research agenda. Special efforts were made to identify a clear set of priorities that reflected both promising and neglected areas of inquiry rather than merely providing a compendium of current or needed research in aging. Particular attention was paid to identification of areas of age-related research that should be supported by the federal government as well as those areas that deserve the attention and support of private foundations. In the final or third stage of this effort, the IOM will work to bring the report to the attention of policymakers, the scientific community, and the general public. The National Research Agenda on Aging builds on two previous documents developed by the NIA—a 1978 report, Our Future Selves, and a 1982 report, Toward an Independent Old Age: A National Plan for Research on Aging —which, taken together, provided an excellent point of departure for the present work. Another major resource was an inventory of federal research on aging, compiled in 1982 by a task force of the U.S. Department of Health and Human Services. The IOM is uniquely qualified to develop this national research agenda on aging. Since its inception in 1970 as a branch of the National Academy of Sciences, one aspect of the IOM's mission has been to advance and protect the health of the public. Several efforts over the past decade have established the IOM as an important national resource for the analysis of health policy issues on aging. These reports include (1) Aging in Medical Education (1978), (2) Health in an Older Society (1985), (3) Improving the Quality of Care in Nursing Homes (1986), (4) Productive Roles in an Older Society (1986), (5) Academic Geriatrics for the Year 2000 (1987), and (6) The Social and Built Environment in an Older Society (1988). The effectiveness of the IOM in influencing public policy is evidenced by the fact that the reports on nursing home care and on academic geriatrics recently led to adoption of federal legislation implementing IOM recommendations. In concluding this analysis, the IOM drew on special strengths: the voluntary nature of the experts' participation in IOM efforts; IOM 's reputation for objectivity; its interdisciplinary membership and perspectives; its collaborative interaction with other components of the National Academy of Sciences; and the thorough, robust, and careful review of all reports prior to their release. The committee applied important criteria in prioritizing research

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Extending Life, Enhancing Life: A National Research Agenda on Aging areas during its deliberations on this project. To qualify for consideration for a prominent place on the National Research Agenda on Aging, the area of research must have fallen within one or more of the following general categories: General aging processes: Such studies focus on theories of aging (diverse mechanisms of aging processes, including genetic and environmental components and their interaction) functioning at the molecular, cellular, organ, organ system, organism, and wider psychosocial and sociocultural levels. Important age-related disease: This might be a disease occurring predominantly in aged populations or a disease found across the lifespan whose occurrence in old age is associated with specific alterations in its presentation, course, or sequelae (e.g., diabetes). Factors influencing age-disease interaction: A number of lifestyle and socioenvironmental factors have an important influence both on the emergence of disease in aging populations and on the mode of presentation by the older victims of disease. The functional capacity of the elderly: The enormous importance of functional capacity as a determinant of the care needs of older persons dictates a special focus on those factors that limit the activity of elderly individuals and impair their independence. The feasibility and timeliness of the research: The committee was sensitive to the fact that “pie-in-the-sky” research agendas must be avoided in favor of feasible research, that is, research whose “time has come. ” Similarly, an overly conservative research strategy must be avoided since major breakthroughs often are made when special, timely windows of opportunity present themselves. Other criteria for areas of research included their potential to (1) enhance research in other areas, as in basic studies on proliferative capacity of cells to improve studies on carcinogenesis; (2) reduce morbidity and mortality in older persons; (3) decrease costs of care; (4) increase knowledge of behavioral and social factors in health and disease; and (5) improve pharmacological treatment of patients. During its deliberations, the committee identified 11 emerging and overarching themes relevant to the entire spectrum of research on aging. These provide a context for the consideration of the individual research areas discussed in the ensuing chapters. An interdisciplinary approach to studies of aging: Many of the most intractable problems in aging research, particularly in the clinical, social, and behavioral arenas, can be properly addressed only by an interdisciplinary group. Interdisciplinary work is costly and

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Extending Life, Enhancing Life: A National Research Agenda on Aging often more difficult to design and conduct successfully than unidisciplinary research. Increasing the body of data based on longitudinal studies: Much of the available information on aging is based on crosscohort studies that compare individuals of different age groups. Although these studies provide some perspective on the effects of aging, they are subject to a number of non-age-related influences, such as secular and cohort effects. Longitudinal studies in which serial prospective measures are made on the same individuals over time provide a much more robust approach to gerontologic and geriatric research. Longitudinal studies, although inherently more time-consuming and expensive than crosscohort studies, are relevant to all domains of research—from basic science through clinical investigation to health services research. Developing research resources—databases, well-defined study populations, cell lines, animal colonies, and animal models for research on aging: Such research resources often can be used by many different investigators conducting various studies at the same time. Federal and, in some cases, foundation funds can be brought to bear to establish such resources. Increasing attention must be given to the types of resources needed to promote the development of aging research to its next level of accomplishment. Areas of neglect—gender, race, cultural background, and ethnicity: Substantial increases in research on aging in members of different racial, cultural, and ethnic groups are needed to clarify the mechanisms underlying differences in the presentation, course, and sequelae of a variety of geriatric-related disorders. Additionally, gender has been shown to have a major influence on biological as well as social and behavioral aspects of aging. Importance of a life-course perspective: Substantial disability and health care expenditures in old age are rooted in the lifestyle, environmental, and other psychosocial factors that begin during youth or middle age. A developmental life-course perspective should be increasingly incorporated into aging research. Emphasis on studying basic mechanisms of aging: Throughout its first phase of development, most gerontologic and geriatric research was descriptive in nature. Studies of the mechanisms of age-related alterations that build on this information and the expanded application of the new and powerful investigative techniques now available are needed. Specialized health promotion and disease prevention research in older populations: A revolutionary increase in life expectancy has occurred already. A corresponding increase in active life expectancy

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Extending Life, Enhancing Life: A National Research Agenda on Aging or health span should be the focus of much of the next phase of aging research. Such an effort must avoid the simple generalization of health promotion/disease prevention research in middle age to older populations. Instead, it should take into account the special physiological characteristics of the elderly and should focus in particular on such disorders as dementia, incontinence, and falls, which are particularly common and disabling in elderly populations. Studies of the role of genetics, social, and environmental factors as modifiers of aging: The effects of the aging process itself have been exaggerated; the modifying effects of the individual's genetic background, nutritional status, exercise, personal habits, and psychosocial factors have been underestimated. The psychological and sociological context of the individual: Interdisciplinary approaches that consider both the influence of the individual's behavior and environment and social interactions and support systems will be crucial. Equally important is the need to explain specific age-related findings. Expansion of health services delivery research: Many of the issues discussed in this section (e.g., the study of the effectiveness of interventions and the investigation of financing of care) may be implemented by the techniques and mechanisms special to the field of health services delivery. This discipline often serves as the interface between scientific application and political policy decisions affecting the delivery of health care to millions of Americans. Health services delivery research can provide objective information to policymakers, assisting them in developing their programs on a more scientific basis and providing tools for analyzing the usefulness of these programs. Ethical considerations in the care of the elderly as a research focus: Previous agendas for research on aging have seriously neglected ethical issues, such as the rationing of health care and the provision of care to and the conduct of research on demented and irreversibly ill older persons, especially with regard to the application of life-sustaining technologies. One of the major scientific challenges for the United States over the next decade will be to enlarge our research capacity in aging so that we gain the knowledge necessary to deal with the health, social, and psychological needs of a rapidly aging society. This plan provides a prioritized and rational blueprint for that research development.