5

Health Services Delivery Research

The existing health care system is fraught with problems for older persons and is best described as chaotic-disorganized, inadequate, and poorly distributed. There are major gaps separating acute and chronic care of older patients, and there is no organized array of services to meet these patients’ chronic care needs or to provide for continuity of care. Equally, the health care system lacks the sensitivity to respond to the changing needs of individual older persons as they experience transitions in health. Although this report focuses on the health needs of the geriatric population, it must not be forgotten that many of the defects in long-term and chronic care apply to younger adults as well.

In the 1990s health care services will continue to be challenged by the changing demands imposed by the projected growth of the older population and especially by the growth of the “oldest old”—those persons 85 years of age and older who are most vulnerable to the problems of ill health and dependency. The growth of the older population will accelerate even more at the beginning of the next century as the baby-boom generation ages. Older persons consume an enormous amount of health services. Over the next decade those persons 80 years of age or older will likely become the largest single federal entitlement group, consuming $82.8 billion annually, includ-ing social security and other benefits (Torrey, 1985). Unfortunately, the response to this growing challenge has been far from adequate.

For example, the rate of production of health professionals (in-



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Extending Life, Enhancing Life: A National Research Agenda on Aging 5 Health Services Delivery Research The existing health care system is fraught with problems for older persons and is best described as chaotic-disorganized, inadequate, and poorly distributed. There are major gaps separating acute and chronic care of older patients, and there is no organized array of services to meet these patients’ chronic care needs or to provide for continuity of care. Equally, the health care system lacks the sensitivity to respond to the changing needs of individual older persons as they experience transitions in health. Although this report focuses on the health needs of the geriatric population, it must not be forgotten that many of the defects in long-term and chronic care apply to younger adults as well. In the 1990s health care services will continue to be challenged by the changing demands imposed by the projected growth of the older population and especially by the growth of the “oldest old”—those persons 85 years of age and older who are most vulnerable to the problems of ill health and dependency. The growth of the older population will accelerate even more at the beginning of the next century as the baby-boom generation ages. Older persons consume an enormous amount of health services. Over the next decade those persons 80 years of age or older will likely become the largest single federal entitlement group, consuming $82.8 billion annually, includ-ing social security and other benefits (Torrey, 1985). Unfortunately, the response to this growing challenge has been far from adequate. For example, the rate of production of health professionals (in-

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Extending Life, Enhancing Life: A National Research Agenda on Aging cluding those in health services delivery) is far short of the goals to provide care for dependent and chronically ill older persons and to meet future needs (National Institute on Aging, 1987). This deficiency will be compounded further by the loss of informal supports as more and more women join the labor force, therefore making them less available to provide care for older relatives. Three trends are likely to influence health policy and health services for older persons in the 1990s: (1) the continuing problem of rising health care costs, (2) the growing concern with quality of care and cost-benefit ratios, and (3) the continuing rapid structural change of the health care service delivery system (Gilford, 1988). Health services research focuses on broadening the knowledge base required to understand and influence the organization, delivery, and financing of health services to older persons. This research area cuts across the other four agenda areas in this report, relying heavily on knowledge from basic research in the biological and psychosocial arenas and linking with clinical research in studies designed to test delivery strategies for proven interventions in a variety of settings. By studying and making more effective the factors that influence delivery of health care to older individuals, research in health services delivery can contribute to decreasing disability and chronic illness, and to improving the quality of life of the older generation. The following issues in health services delivery were identified by the committee as having greatest relevance to the research priorities listed in the next section: long-term care and continuity of care for older persons; financing health care for older persons; drug use and mental health services for older persons; and disability/disease prevention and health promotion services for older persons. Implicit in research involving these areas are questions regarding (1) the extent to which functional status and/or quality of life for older persons is improved with various treatment options and (2) the efficacy and cost of care. This focus on effectiveness, outcome, and functional independence fits well with the new direction being taken by federal research centers. An extended discussion of the issues related to health services research in aging appears in the Health Services Delivery Research Liaison Team report (see Appendix B).

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Extending Life, Enhancing Life: A National Research Agenda on Aging LONG-TERM CARE AND CONTINUITY OF CARE FOR OLDER PERSONS While there remain many unanswered questions concerning health services research related to older persons, the most pressing are those involving continuity of care, particularly with respect to long-term care. The objectives of long-term care are to help older persons cope with their disabilities, decrease dependence on others, and narrow the gap between actual and potential functioning (U.S. Department of Health and Human Services, 1980). Our system for delivering and financing long-term care is in an embryonic developmental state. A majority of the long-term care needs of this population are unmet or met by families (particularly the female spouse or daughters of the disabled older person), clearly indicating the need for governmental support of these important caregivers. Long-term care is defined in a number of ways. The Health Care Financing Administration, the major federal agency involved in payment for long-term care for older persons, defines it as follows: “Long-term care refers to health, social and residential services provided to chronically disabled persons over an extended period of time. The need for long-term care is not necessarily identified with a particular diagnosis, but rather physical or mental disabilities that impair function in activities of daily living” (Doty et al., 1985). A second definition can be found in the introduction to the Long-term Health Care Minimum Data Set: “Long-term health care refers to the professional or personal services required on a recurring or continuous basis by an individual because of chronic or permanent physical or mental impairment. These services may be provided in a variety of settings including the client's home” (U.S. Department of Health and Human Services, 1980). These and other definitions of long-term care (Kane and Kane, 1987) share two common elements: (1) the care continues over an extended period of time and provides varying degrees of intensity and resource deployment; (2) it is provided to persons who have lost (or never had) the capacity to care for themselves because of a chronic physical or mental illness or condition (Gilford, 1988). The transition between acute and long-term care is complicated because the mechanisms that provide continuity of care for patients moving between acute and long-term care are not well developed. Consequently, issues surrounding continuity of care continue to plague older persons, their families, health care providers, and researchers.

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Extending Life, Enhancing Life: A National Research Agenda on Aging Characteristics of Older Persons Requiring Long-Term Care As noted in the Executive Summary and Recommendations for Funding, chronic diseases have become major contributors to death and disability among older persons in this country. However, the Panel for Statistics for an Aging Population (Gilford, 1988) states that “the diagnostic description of a person is seldom an indicator of his or her need for or utilization of long-term care because diagnosis alone gives no clue to how well or how poorly an individual functions. As a result, descriptions of behavior, rather than conditions, are used to describe the long-term care population.” About 20 percent of those 65 years of age and older need assistance to carry out some basic functions of adult life (LaPlante, 1988; Rice and LaPlante, 1988). Because of the dramatic and varied effect of age on disability, morbidity, and mortality, and because the older population is a widely heterogeneous group, investigators have suggested dividing this population into age subgroups. Gilford (1988), for instance, recommends three subgroups for health research purposes: the young-old (65 to 74 years), the old (75 to 84 years), and the oldest-old (85 years of age and over). This last group is most vulnerable to disability and the problems associated with ill health and frailty, and is most in need of long-term care services. Data collection related to the natural history of chronic illness and disability, functional status, behavioral problems, and quality of life should be supported and expanded, with particular attention paid to changing cohorts (one-third of the membership in the aged population changes every 5 years). The recent mandate to collect functional status data on nursing home residents will provide a needed database on that population. Much more research is needed to elucidate the characteristics of special populations of older persons requiring long-term care. For example, little is known about how ethnic and class differences influence the need for or access to care. Informal Providers of Long-Term Care Family members and friends provide over 80 percent of all long-term care for older persons. Most caregivers are women; about 60 percent are 65 years old or older. More than 40 percent of those giving care rate their health as fair or poor, and over a third rate their health as poor or near poor (Stone et al., 1987). The past decade of research indicates that family caregiving is a complex phenomenon. Tremendous variability exists in the nature of the care provided by family members, the stress and rewards related to that care on the part of the caregiver and older person, and

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Extending Life, Enhancing Life: A National Research Agenda on Aging the relationship between the formal and informal systems of care. Caregiving can be stressful for the caregiver and other family members (Zarit et al., 1986). In fact, recent research has shown that family members of older persons suffering from mental health problems are at risk for developing their own mental disorders (National Institute of Mental Health, 1988). Those family members providing care to older family members receive little help from the formal health care system, for policymakers are concerned that extending publicly supported services to caregiving families might reduce the amount of family care provided to older persons. However, available evidence in this area suggests the opposite: the addition of formal services to a family caregiving situation does not reduce the amount of informal help provided to the older person (Stephens and Christianson, 1986). Although our understanding of the phenomenon of family caregiving is increasing, we lack knowledge regarding caregiving among special populations (e.g., minority elderly persons, low-income elderly persons, elderly persons living alone), appropriate interventions for caregivers, and targeting interventions for this group (Brody, 1990). The nation depends on the family to provide most long-term care services in the community, but the knowledge base regarding how to assist family caregivers is inadequate. Formal Long-Term Care Organized long-term care in this country has been criticized as expensive, inadequate, disorganized, and biased toward institutional care (Harrington et al., 1985; Kane and Kane, 1987). The continuity of care between acute and long-term care is not well developed and often nonexistent (Estes, 1988). During the past decade, attempts have been made to address these problems in long-term care. Results of these long-term care demonstrations (e.g., the channeling experiments) are difficult to interpret because of methodological problems encountered in the studies, but the hope that high-quality long-term care could be paid for with dollars recouped from the prevention of hospital care was not realized (Weissert et al., 1988). Several criticisms have been directed at past long-term care experiments: (1) they failed to account for the complex and changing nature of long-term care needs; (2) the outcome measures used to evaluate such interventions were inappropriate; and (3) criteria for the selection of persons receiving such interventions were not appropriate. Results of long-term care demonstrations, however, do sug-

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Extending Life, Enhancing Life: A National Research Agenda on Aging gest an avenue for further research: both the conceptualization of long-term care and the methods used to study the efficacy of such services need to be reviewed. In addition, management mechanisms, such as case management, that are designed to facilitate continuity of care need to be evaluated. Supply of Personnel for Long-Term Care As our population ages, institutional and community-based long-term care systems are and will continue to be confronted with increasing numbers of older persons. Without intervention the recruitment, training, motivation, and reward of a competent work force to meet this population 's service needs will continue to be insufficient. To a great degree this problem represents an economic and personnel issue, not a research question. The central questions are the following: Who should provide long-term care, and how can we pay the providers? To the extent that research can elucidate underlying factors affecting the choice of long-term care careers, work satisfaction, job design, and other work force-related matters, it should be supported. Since long-term care providers are generally women, many are also poor and many are members of minority groups. From the provider' s perspective the issues confronting workers in long-term care settings are “women's issues”—poor salaries and benefits, low job security, and lack of flexibility in scheduling. In many states, infact, nonprofessional providers of long-term care are paid no better than the minimum wage. Additionally, the gerontological and long-term care content of traditional physician, nurse, and social worker educational programs is inadequate (National Institute on Aging, 1987). Numerous professionals are involved in delivering health care to older persons; their roles, however, are not clearly defined. Research focusing on role definition and the costs and benefits of alternative long-term care providers should be undertaken. In order to avert a crisis within the next decade, research and demonstration programs that focus on the recruitment, training, retention, and quality of both nonprofessionals and professionals in long-term care are needed immediately. Locus of Long-Term Care At this point, little agreement exists about the most appropriate locus of long-term care. Is it the hospital, the home, the nursing home, or another long-term care facility? Research is needed to

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Extending Life, Enhancing Life: A National Research Agenda on Aging evaluate the attributes of each of these settings in relation to long-term care, the attributes of persons providing care within these settings, and the ability of specific settings to adjust to the changing needs and personal resources of older persons. Quality Assurance The interactions among the need for care (based on functional status), the nature of long-term care intervention, and the outcome of care are poorly understood. Lacking are standards for long-term care and valid and reliable measures of the need for and quality of care, including quality of care at different sites (e.g., home care), and instances where quality of care may conflict with quality of life. Development of such standards and measures for community-based care is particularly critical because of the shift in locus of care to the community. Such measures include indices of the quality of family care along with the quality of formal community care. Several issues that cross health services and clinical research areas require attention. First, information about how a provider's perception of age and aging might affect treatment decisions in long-term care is essential. Second, research focusing on understanding rehabilitation strategies and their relationship to treatment outcomes is needed. Technologies Recent technical advances have the potential to enhance life for many disabled people, but little work has been done to delineate the positive and negative effects of such technologies. Three categories of technology are relevant to long-term care: (1) universal technologies (those shaping the environment in home and community to enhance, or to inhibit, independence), (2) individual technologies (those providing aids to individuals to help overcome deficits), and (3) life-sustaining technologies (those replacing or supplementing failed organs or bodily systems). The use of these technologies is value laden and leads to central questions that have not been addressed in our society. This and other ethical issues are discussed further in Chapter 6. Theoretical development in the area of universal technologies suggests that such strategies may be key to reducing the need for both individual aids and service interventions (Orleans and Orleans, 1985; Zola, 1988). This area needs more research attention and represents a promising research direction.

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Extending Life, Enhancing Life: A National Research Agenda on Aging FINANCING OF HEALTH CARE FOR OLDER PERSONS Because of increased health care expenditures by federal and state governments and by individual older persons, health care financing has become one of the most critical issues to be addressed by the nation. Spending on health care services increased at an annual rate of 14.5 percent between 1977 and 1984 (Waldo and Lazenby, 1984) and has continued to increase since that time, but there is no evidence of a comparative improvement in health outcome. To a great degree, the methods used to finance health services govern both the nature of the services used by and available to older persons and the growth and development of the health and social service systems per se (Gilford, 1988). Policymakers and health services researchers are confronted by five major issues related to the cost and financing of health care for older persons: (1) the continuing increase in the cost of health care despite efforts to restrain spending; (2) the highly concentrated distribution of health care expenses in which very few persons actually consume the majority of health care resources; (3) the individual and societal consequences of a health care policy that does not cover the costs of long-term care; (4) the impact of poverty on health status and access to care; and (5) the lack of suitable health care outcome measures. These issues are complicated further by the fact that positive health is not distributed equally across society. Poverty negatively affects health; ill health impoverishes. Consequently, older persons most in need of health care are vulnerable not only because of ill health but also because of poverty. Since poverty is not distributed equally throughout the population but is more prevalent among women and members of minority groups, older persons who are poor, female, and members of a minority group are most vulnerable to the problems of illness. These matters require research to help resolve the problems of health care financing for older persons. First, the factors that determine patterns of public and private health insurance arrangements for older persons must be understood. Of particular interest is the problem encountered by many older persons who have multiple insurance policies, overlapping or inadequate coverage, or health policies as part of the retirement benefits provided by government and industry. The failure of this fractured structure to protect many of the aged who are chronically ill stresses the urgency for intensive research on long-term care insurance for this vulnerable population. Second, the effects of financial barriers on access to and use of health services and on the health status of older persons must be better

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Extending Life, Enhancing Life: A National Research Agenda on Aging understood. Third, research related to the distribution of risk should be approached from a theoretical framework to guide definition and selection of risk factors and data collection. At present, models are tested using data that may not be appropriate. For example, investigators limited by inadequate research support have been forced to use data collected earlier by Medicare; these data often fail to identify the presence or absence of family caregivers or other supports for older persons. More work is needed to examine how financing and regulations shape the care system (by providing incentives for sites and types of care) and how Medicare policies influence screening and preventive services for older clients. Research should be directed toward better understanding providers who demonstrate inappropriate responses to older persons. Finally, more study is needed of careers in chronic care and of the cost of different levels and patterns of chronic care. DRUG USE Whereas persons 65 years old and over comprise about 12 percent of the U.S. population, they receive about 25 percent of the total number of prescriptions dispensed, and they account for about 30 percent of annual U.S. prescription drug expenditures. Three major and well-founded concerns arise in the area of geriatric drug use: inappropriate physician prescribing, widespread elderly patient noncompliance with drug regimens, and increasing drug prices. Inappropriate Prescribing Our body of knowledge regarding the effects of aging on drug therapy and drug metabolism is extensive (Bender, 1974; Lamy, 1984; Lipton and Lee, 1988; Montamat et al., 1989). However, increasing evidence indicates that prescribers do not follow the guidelines set forth in this research. Thus, a number of problems arise in the process of prescribing: a drug may be ordered when no drug is needed, or a prescription may be made for the wrong drug, a suboptimal drug, the incorrect dosage, or a dosage without knowledge of other medications being taken. Evidence of geriatric prescribing problems can be found in the high rate of drug-related hospitalizations among older people. Among all patients admitted to the hospital, patients 65 years old and older have the highest admission rates (10 to 25 percent) for drug-induced symptoms, and this problem appears not to have changed significantly during the past decade (Levy et al., 1979; Bergman and Wilholm,

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Extending Life, Enhancing Life: A National Research Agenda on Aging 1981; Ives et al., 1987). Recent studies focusing on geriatric patients suggest that 10 to 31 percent of hospital admissions are associated with drug-related problems (Williamson and Chopin, 1980; Popplewell and Henschke, 1982; Grymonpre et al., 1988). Drug-induced hospitalizations are associated with appreciable morbidity and mortality; the cost of such hospital care is estimated at $4.5 to $7 billion annually (Kusserow, 1989). Although most of the studies identify specific drug classes implicated in drug admissions, they do not identify the specific reasons the drugs are associated with the problem. For example, if a given drug is responsible for a hospital admission, is the problem related to drug dosage, drug schedule, drug allergy, drug duplication, drug-drug interaction, or drug selection? Additional research is needed to add to our understanding of the mechanisms through which specific drugs lead to problems associated with hospitalization. We also need to learn more about the incidence of prescribing problems among older persons living in the community. The cumulative burden of drug-related morbidity among elderly outpatients may have enormous clinical and economic consequences. Noncompliance Older persons are more likely than younger persons to misuse medications (Cooper et al., 1978; Lamy, 1984; Darnell et al., 1986). A systematic investigation of communication among patients and providers should be undertaken to assess the extent to which good communication enhances compliance on the part of older persons (Lipton and Lee, 1988). Systems of information retrieval for physicians, pharmacists, and other providers should be developed and evaluated. Finally, demonstrations are needed to test approaches to improve compliance by older populations. Because the aging process alters pharmacodynamics and pharmacokinetics, older persons are at risk for untoward drug effects (Law and Chalmers, 1976; Kiernan and Isaacs, 1981). In addition, many older persons with multiple chronic illnesses take more than one drug, increasing the chance of an adverse drug reaction (Steel et al., 1981; Hutchinson et al., 1986). While we know that older persons are at risk for drug reactions for several reasons, we do not know the extent to which older persons are at risk. Work by Lipton and Lee (1988) identifies multiple strategies to reduce these risks through such broad-based interventions as modified labeling and simplified drug schedules.

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Extending Life, Enhancing Life: A National Research Agenda on Aging Drug Costs and Older Persons National expenditures for “drugs and medical sundries”—a category that includes prescription and nonprescription drugs and medical supplies dispensed through retail channels—accounted for almost 7 percent of health spending or $34 billion in 1987. Drug costs totaled about $9 billion for older persons that year. The number of drugs prescribed increases with age, and the average price of prescriptions also rises with age. Overall, older persons pay 14 percent more per prescription than do those under age 65. It is important to note that older persons are not being charged more for their medications. Rather, they take a different mix of drugs, and their prescriptions extend over a long-term, not acute, treatment period. Because they use more drugs and pay higher prices for prescriptions than do younger patients, older patients are more likely than other age groups to incur high drug costs. They are also more likely to pay a higher percentage of out-of-pocket expenses for drugs. What about the demographic distribution of drug expenses incurred by older persons? Results of a 1980 national survey revealed that the proportion of prescription drug expenses reimbursed by private insurance was similar for both poor and near poor older persons: 7.7 percent and 10.7 percent, respectively. However, that statistic rises significantly—up to 20.6 percent—for those who are not poor. All three groups had out-of-pocket expenses of approximately half of the total costs of drugs. The near poor (those living in families whose income is above the poverty level but less than or equal to twice the poverty level) are particularly vulnerable to this out-of-pocket cost burden. It is important to emphasize that this information was collected in 1980, before the escalation of drug prices. Since 1981, prescription drug prices have increased two to three times faster than all other consumer prices (Lipton and Lee, 1988). As a result, drug prices have become a source of growing concern for consumers, policymakers, and both individual and institutional purchasers. Although the real income of the aged poor and near poor has remained relatively static in recent years, with Social Security payments increasing at the same rate as inflation, the expenditure for drugs most likely has increased as the result of drug price inflation. Therefore, drug expenditures relative to income may be even greater now than at the time of the 1980 survey.

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Extending Life, Enhancing Life: A National Research Agenda on Aging MENTAL HEALTH SERVICES There is growing interest in the older person's use of mental health services, with some researchers noting that older persons seem to use fewer mental health services than do younger persons (German et al., 1985; Leaf et al., 1985; Borson et al., 1986; German et al., 1987; Goldstrom et al., 1987; Lurie and Swan, 1987). The need to understand the older person's use (or nonuse) of mental health services is important for several reasons: (1) the high incidence of dementia in the older population, (2) the high prevalence of mental impairment of older persons in nursing homes, and (3) the high prevalence of alcohol abuse or dependency among older persons admitted to county or state mental hospitals. In the community 10 to 25 percent of older persons have some degree of mental impairment. Among men, the incidence of suicide dramatically increases with age. In short, mental illness is common in older persons, but often is untreated. Research is needed to investigate how older persons use mental health services and why. Of particular interest are the effects of race, gender, and social status on service utilization. Alzheimer's disease is widely recognized as the major mental health problem of the older population, but little is known about its epidemiology and treatment. Of particular interest is the delineation of risk factors associated with dementia. Depression is another common problem of late adulthood; yet because there is little agreement on the definition of this condition, depression in older people may not be recognized widely. From a health services perspective, innovative methods for the treatment of depression that are acceptable to older persons should be developed and evaluated. Our understanding of the less common clinical problems of aging—schizophrenia, bipolar disease, and other psychotic conditions—is very limited. Research is needed to examine both those who develop a psychotic condition, such as paranoia, in older age and those who were diagnosed with such disorders earlier in life. Even where our knowledge base is firm, clinicians providing the bulk of services to older persons may not recognize the signs and symptoms of major mental illness. Investigation is critically needed on mental illness in special populations of older persons. Little is known, for example, about the mental health status or needs of older persons who are members of minority groups. Of the older population, those who are institutionalized have the least understood but highest prevalence of mental disorders (National Institute of Mental Health, 1988). We do not know what services are available to this group, nor do we know what services are needed or how they should be financed. Research also is

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Extending Life, Enhancing Life: A National Research Agenda on Aging needed to elucidate the interactive processes among disability, disease, mental health, the environment, and the cost of health services. Such a holistic approach should lead to a better understanding of the panoply of services needed by older persons. Finally, research is required to elucidate the cost and outcomes of various patterns of mental health care. How well, for example, do community mental health centers meet the needs of older persons? These data should be related to the reimbursement system that currently does not pay for many types of mental health services. DISABILITY/DISEASE PREVENTION AND HEALTH PROMOTION SERVICES Although some work has been undertaken in the area of disease prevention through risk reduction,*there is still a crucial need for clinical research in this area. Lacking is consistent evidence regarding the effects of risk reduction on the presence of disease conditions; no systematic research has been undertaken on risk reduction in late adulthood. Lifestyle prescriptions for older populations are now based on research done on younger populations. Several clinical research questions need to be answered before health services research can proceed: Are accepted risk factors for disease the same in direction and magnitude for older persons as they are for younger persons? What are the prevalence estimates for specific risk factors by demographics within the older population? Are interventions known to be effective with younger persons equally effective and acceptable in reducing risk in older people? Does the reduction of risk factors make any difference in the health status of older persons? What is the relationship between disease and disability? If research does support the need for intervention, then demonstrations designed to deliver preventive services to older persons should be developed. Research also is needed to identify risk factors for disability; risk-reduction programs can then be developed and evaluated. *   See the Institute of Medicine's 1990 report, The Second Fifty Years: Promoting Health and Preventing Disability (Washington, D.C.: National Academy Press).

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Extending Life, Enhancing Life: A National Research Agenda on Aging RESEARCH PRIORITIES The committee identified five research priorities in the area of health services research. These priorities represent the broad areas within which specific research questions and proposals can be framed. It is noteworthy that the field of health services delivery, as with some aspects of clinical science and behavioral and social studies, offers opportunities for research in nursing and other aspects of health care that may contribute significantly to the field of investigation of aging. The committee proposes that research be undertaken into long-term care and continuity of care for older persons. This priority area includes research into factors that determine the need for and use of long-term care services, questions regarding the organization and delivery of long-term care services, the special role of the family in the delivery of care, and the growing question of adapting modern technology to enhance the ability of older persons to live independently. Also included in this category is research into the nature of the hospital as an institution and the role of nursing facilities and health care institutions for the older person. Finally, this priority area includes research at three levels—the individual, the institution, and the society—that affect recruitment, training, and quality of providers of both formal and informal long-term care. The committee recommends research on the cost and financing of health care in the older population. This priority area includes research into reducing financial barriers to care for older persons. Of particular interest are questions related to financing of insurance for older persons, most notably coverage for long-term care, mental health, rehabilitation, and disease prevention and health promotion services. Studies of outcome measures in this area also are important. The committee recommends research on drug therapy in older persons. This priority area includes research into the factors influencing the development and regulatory approval of drugs and the effectiveness and efficiency of prescribing, dispensing, and taking pharmaceuticals. Equally, research should be undertaken into drug-related phenomena that affect the social and physical functioning of older persons.

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Extending Life, Enhancing Life: A National Research Agenda on Aging The committee recommends research on mental health services in the older population. This priority area includes research into the factors that determine the need for and use of mental health services, the role of treatment for mental illness as a factor in improving the social and physical functioning of older persons, and the effect of early life treatment in reducing later-life disability from mental disorders. The committee recommends research on disability/disease prevention and health promotion in older persons. This priority area includes research into developing new models for the delivery of appropriate behavior change programs for elderly populations. ADDITIONAL RESEARCH OPPORTUNITIES The committee considers the preceding five research priorities to be the most critical. Additional important opportunities in health services delivery research include research into alternative methods of delivering long-term care, including models that focus on a particular subgroup (e.g., posthospital management) and that provide linkage of housing arrangements with community long-term care facilities; research to examine the effect of employer-initiated cost sharing on the use of preventive and treatment services by older persons; research on the effect of interventions to reduce the incidence of inappropriate drug treatment decisions by physicians; research to study the provision of mental health services to elderly institutionalized persons in the context of need, utility, and outcome; and research to investigate and compare the relative contribution of accepted risk factors in the development of disease among young and aged populations. RESOURCES REQUIRED The committee recommends increased support over current health services research spending during the next 5 years for increased funding of research, for construction, for training, for the expansion of infrastructure (databases, library support, computer capability), and for the addition of new Centers of Excellence in Geriatric and Gerontological Research and Training (Claude Pepper Centers). Funding needs are described in greater detail in the Executive Summary and Recommendations for Funding. Specifically, increased funding in age-related research is recommended in order to raise the number of approved grants that are funded from less than one in four (24

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Extending Life, Enhancing Life: A National Research Agenda on Aging percent) to one in two. In addition to the dollars for research activities, funds are needed to support a minimum of 140 additional predoctoral and postdoctoral fellowships per year for training in health services research careers, for specific infrastructure needs, and for construction costs. Health services research also will participate in the added funds for support of programs of geriatric and gerontological research that are located within current medical centers (administrative locus, as compared with geographically established centers). CROSS-DISCIPLINARY AND CROSSCUTTING ISSUES Most of the research priorities identified in this chapter cross disciplinary lines, focusing on issues that benefit from clinical, behavioral, and social science as well as health services research. Beyond that, four key crosscutting issues must be addressed directly. First, an understanding of the effects of gender, class, and ethnicity is salient to every priority area listed in this chapter. Second, ethical issues that must be thoughtfully analyzed and researched are embedded in each priority. Third, save in specific areas, health services research in the area of health promotion/disease prevention cannot proceed until clinical research provides clear mechanisms for risk reduction in the older age groups. This need has been identified by Lipton and Lee (1988) who state with respect to drug use research: Despite the existence of a great deal of information regarding drug therapy and older patients (especially information gathered in recent years), there is a need for more research. Areas requiring further study include the nature of age-related biological, physiological and pathological changes; ways in which these changes affect the elderly person's response to drugs; and the kinds of drug prescribing, dispensing, and administration appropriate to deal with these changes. An area that has remained virtually unexamined involves the psychological changes (e.g., depression) and social changes (e.g., loss of spouse) that accompany aging and the way they affect the older person's need for, use of, and response to drugs. Drug epidemiology studies—large-scale studies of drug use and its relationship to clinical outcomes—are urgently needed in elderly populations, especially with regard to psychotropic agents. Private foundations and federal funding agencies (particularly the National Institutes of Health and the Alcohol, Drug Abuse and Mental Health Administration) should give these areas high priority on their agendas. Fourth, the dynamic nature of both the aging process and the health care delivery system means that there is a great need for longitudinal research. Most of the research areas in this section can best be

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Extending Life, Enhancing Life: A National Research Agenda on Aging addressed using this approach. Longitudinal research is complicated by a series of predictable methodological and situational issues that must be taken into account when planning for resources in this area. REFERENCES Bender, A. D. 1974. Pharmacodynamic principles of drug therapy in the aged. Journal of the American Geriatrics Society 22: 296-303. Bergman, U., and B. E. Wilholm. 1981. Drug-related problems causing admission to a medical clinic. European Journal of Clinical Pharmacology 20: 193-200. Borson, S., R. A. Barnes, W. A. Kukull, J. T. Okimoto, R. C. Veith, T. S. Inui, W. Carter, and M. A. Raskind. 1986. Symptomatic depression in elderly medical outpatients. 1. Prevalence, demography, and health service utilization. Journal of the American Geriatrics Society 34: 341-347. Brody, E. 1990. Women in the Middle. New York: Springer Publishing. Cooper, J. W., and C. G. Bagwell. 1978. Contribution of the consultant pharmacist to rational drug usage in the long-term facility. Journal of the American Geriatrics Society 26: 513-520. Darnell, J. C., M. D. Murray, B. L. Martz, and M. Weinberger. 1986. Medication use by ambulatory elderly: An in-home survey. Journal of the American Geriatrics Society 34: 1-4. Doty, P., K. Liu, and J. Weiner. 1985. Special report: An overview of long-term care. Health Care Financing Review 6: 69-78. Estes, C. 1988. Cost-containment and the elderly: Conflict or challenge? Journal of the American Geriatrics Society 36: 68-72. German, P. S., S. Shapiro, and E. A. Skinner. 1985. Mental health of the elderly: Use of health and mental health services Journal of the American Geriatrics Society 33: 246-252. German, P. S., S. Shapiro, E. A. Skinner, M. Von Korff, L. E. Klein, R. W. Turner, M. L. Teitelbaum, J. Burke, and B. J. Burns. 1987. Detection and management of mental health problems of older patients by primary care providers. Journal of the American Medical Association 257: 489-493. Gilford, D. M. 1988. The Aging Population in the Twenty-first Century. Washington, D.C.: National Academy Press. Goldstrom, I. D., B. J. Burns, L. G. Kessler, M. A. Feuerberg, D. B. Larson, N. E. Miller, and W. J. Cromer. 1987. Mental health services use by elderly adults in a primary care setting Journal of Gerontology 42: 147-153. Grymonpre, R. E., P. A. Mitenko, D. S. Sitar, F. Y. Aoke, and P. R. Montgomery. 1988. Drug-associated hospital admissions in older medical patients. Journal of the American Geriatrics Society 36: 1094-1098. Harrington, C., R. J. Newcomer, and C. L. Estes. 1985. Long Term Care of the Elderly: Public Policy Issues. Beverly Hills, Calif.: Sage. Hutchinson, T. A., M. M. Flegel, M. S. Kramer, D. G. Leduc, and H. H. Kong. 1986. Frequency, severity, and risk factors for adverse reactions in adult outpatients: A prospective study. Journal of Chronic Disease 39: 533-542. Ives, T. J., E. J. Bentz, and R. E. Gwyther. 1987. Drug-related admissions to a family medicine inpatient service. Archives of Internal Medicine 147: 1117-1120. Kane, R. A., and R. L. Kane. 1987. Long-Term Care: Principles, Programs and Policies. New York: Springer Publishing.

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Extending Life, Enhancing Life: A National Research Agenda on Aging Kiernan, P. J., and J. B. Isaacs. 1981. Use of drugs by the elderly. Journal of the Royal Society of Medicine 74: 196-200. Kusserow, R. P. 1989. Medicare Drug Utilization Review. Washington, D.C.: Office of the Inspector General. Lamy, P. P. 1984. Hazards of drug use in the elderly. Postgraduate Medicine 76: 50-53, 56-57, 60-61. LaPlante, M. 1988. Data on Disability from the National Health Interview Survey, 1983-1984 Report 88-P-6, prepared with InfoUse. Washington, D.C.: National Institute on Disability and Rehabilitation Research. Law, R., and C. Chalmers. 1976. Medicines and elderly people: A general practice survey. British Medical Journal 1(609): 565-568. Leaf, P. J., M. M. Livingston, G. L. Tischler, M. M. Weissman, C. E. Holzer III, and J. K. Myers. 1985. Contact with health professionals for the treatment of psychiatric and emotional problems. Medical Care 23: 1322-1337. Levy, M., M. Lipshitz, and M. Eliakim. 1979. Hospital admissions due to adverse drug reactions. American Journal of Medicine 39: 49-56. Lipton, H. P., and P. R. Lee. 1988. Drugs and the Elderly: Clinical, Social and Policy Perspectives. Stanford, Calif.: Stanford University Press. Lurie, E. E., and J. H. Swan. 1987. Serving the Mentally Ill Elderly: Problems and Perspectives. Lexington, Mass.: Lexington/Heath. Montamat, S. C., B. J. Cusack, and R. E. Vestal. 1989. Management of drug therapy in the elderly. New England Journal of Medicine 321: 303-309. National Institute of Mental Health. 1988. Research and Activities Report of the Mental Disorders of the Aging Research Branch (mimeo). Rockville, Md. National Institute on Aging. 1987. Personnel for health needs of the elderly through year 2020. In Administrative Document of the U.S. Department of Health and Human Services. Washington, D.C.: U.S. Government Printing Office. Orleans, M., and P. Orleans. 1985. High and low technology: Sustaining life at home. International Journal of Technology Assessment in Health Care 1: 353-364. Popplewell, P. Y., and P. J. Henschke. 1982. Acute admissions to a geriatric assessment unit. Medical Journal of Australia 1: 343-344. Rice, D. P., and M. LaPlante. 1988. Chronic illness, disability, and increasing longevity. Pp. 5-55 in The Economics and Ethics of Long-Term Care and Disability, S. Sullivan and M. E. Lewin, eds. Washington, D.C.: American Enterprise Institute for Public Policy Research. Steel, K., P. M. Gertman, C. Creszeni, and J. Anderson. 1981. Iatrogenic illness on a general medical service at a university hospital New England Journal of Medicine 304: 638-642. Stephens, S. A., and J. B. Christianson. 1986. Informal Care of the Elderly. Lexington, Mass.: Lexington Books. Stone, R., G. L. Cafferata, and J. Sangl. 1987. Caregivers of frail elderly. The Gerontologist 27: 616-626. Torrey, B. 1985. Sharing increasing costs on declining income: The visible dilemma of the invisible aged. Milbank Memorial Fund Quarterly; Health and Society 63: 377-394. U.S. Department of Health and Human Services. 1980. Report of the National Committee on Vital and Health Statistics. Long-Term Health Care Minimum Data Set. DHHS Pub, No. (PHS)80-1158. Hyattsville, Md.: Office of Health Research, Statistics, and Technology, National Center for Health Statistics.

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Extending Life, Enhancing Life: A National Research Agenda on Aging Waldo, D., and H. Lazenby. 1984. Demographic characteristics and health care use and expenditures by the aged in the U.S.: 1972–1984. Health Care Financing Review 6: 1-29. Weissert, W. G., C. M. Cready, and J. E. Pawelak. 1988. The past and future of home- and community-based long-term care. Milbank Memorial Fund Quarterly; Health and Society 66: 309-388. Williamson, J., and J. M. Chopin. 1980. Adverse reactions to prescribed drugs in the elderly: A multicenter investigation. Age and Ageing 9: 73-80. Zarit, S. H., P. A. Todd, and J. M. Zarit. 1986. Subjective burden of husbands and wives as caregivers: A longitudinal study. The Gerontologist 26: 260-266. Zola, I. K. 1988. Policies and programs concerning aging and disability: Toward a unifying agenda. Pp. 90-130 in The Economics and Ethics of Long-Term Care and Disability, S. Sullivan and M. E. Lewin, eds. Washington, D.C.: American Enterprise Institute for Public Policy Research.