S ELVES National Institutes of Health ’ 130:5}me ‘ , w I 1: Eye}; \1“ " OURFUTU : ARES C T S I SUP’NQRY REPORTS PANELS ON BIOMEDICAL RESEARCH BEHAVIORAL AND SOCIAL SCIENCES RESEARCH RESEARCH ON HLMAN SERVICES AND DELIVERY SYSTEMS OF THE [ NATIONAL ADVISORY COUNCIL ON AGING fl. U. S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE NATIONAL INSTITUTES OF HEALTH DHEN PUBLICATION NO. (NIH) 78-1Ll46 F0: sale by the Supetlntendent of Documents, U.8. Government Prlntlng Office, Washington, DC. 20402 '\ 9p PUEL‘ H u 1064 U5 086 PUBL Foreword This volume is a summary of the principal issues and recommendations for re— search on aging and the problems of the aged as presented by panels of the National Advisory Council on Aging. The volume is concerned with biomedical research, be- havioral and social research, and research on human services and delivery. The full reports on which this summary volume is based are also available. The material in this summary volume and in the full reports is the foundation upon which the federal research plan on aging is based. This plan was prepared by the National Institute on Aging and transmitted in late I976 to the Congress by the Secretary of Health, Education, and Welfare. That this summary volume as well as the detailed reports exist is due in large part to the hard work and enormous dedication of the National Advisory Council on Aging. Particular gratitude is due those members of the Council directly responsible for preparing the reports and those in all disciplines who contributed freely of their knowledge, wisdom, and criticism. This effort has strengthened the new National Institute on Aging and will, as the recommendations bear fruit in the results of research and their eventual applications, better the lives of America's aged. Robert N. Butler, M.D. Director, National Institute on Aging Contents Biomedical Research Behavioral and Social Sciences Research Research on Human Services and Delivery Systems Biomedical Research The goal of biomedical research on aging is to prolong the useful and active lives of the elderly and to raise the quality of their lives. That can be accomplished if we understand the normal process of aging, the nature of diseases common to the aged, and the sources and remedies for many of the painful disabilities suffered by the aged. The major systems within the body may lose their functions at different rates, depending upon the genetic blueprint and environmental experiences of the individual, although evolution has insured that, for most individuals, these rates of failure are not so out of synchrony as to interfere with reproduction. One goal of biomedical research, then, is to characterize, for the various systems, the progressive loss of function that occurs as the human being grows older. We must discover how the basic biologic proc— esses of aging predispose people to a great variety of disabilities. In addition to more subtle and insidious infirmities, such as progressive loss of muscle strength, these disa- bilities include a striking array of major disease processes: arteriosclerosis (hardening of the arteries), the most common forms of cancer (skin, lung, and gastrointestinal tract), diabetes (the most common form), obesity, osteoporosis (loss of bone mass), osteoarthri- tis (chronic degenerative joint disease), benign prostatic hypertrophy (enlargement of the prostate gland), pulmonary emphysema, cataracts, depression, and senile dementia (mental deterioration). ‘ Research on the biology of aging involves virtually all of the major ailments of modern man. However, the approach of investigators in aging research is unique: The emphasis is not so much on the specific disease process, but on the genetically control- led, time-dependent mechanisms that result in progressive changes in structure and ‘ function of the body, changes that are likely to set the stage for disease. Investigations must be carried out on many levels —- molecular cell, tissue, organ, organ system, indi- vidual, and population. Eventually, a detailed understanding should emerge of how some interactions between an individual's nature (his genetic endowment) and nurture (the environment to which he is exposed) result in premature senescence of the brain, while others result in premature death from the complications of severe arteriosclerosis or in disability from osteoporosis. It is hoped that means of retarding or preventing these processes in susceptible individuals can be developed. l l l l In this report, the state of the art and priority areas of research in biological and medical aspects of aging are highlighted. Biomedical research in aging may be usefully categorized into three major areas: basic biological aspects of aging (intrinsic aging), interaction of aging and disease, and interaction of aging and external influences. Chair: Edwin L. Bierman, M.D., School of Medicine, The University of Washington, Seattle, Washington. Co—chair: Harold Brody, Ph.D., M.D., Faculty of Health Sciences, The State University of New York at Buffalo, Buffalo, New York. Basic aspects of aging that may influence investigations at various levels of bio- logical organization include: I) Genetics of aging. 2) Mutation and repair of genetic material. 3) Ability of cells to synthesize and maintain key molecular components. 4) Maintenance and integrity of cellular organelles. 5) Cell function and loss. 6) Physiological function and decline. Studies on the interaction of aging and disease should, while focusing on specific diseases common to the elderly, attempt to resolve the classical dilemmas of "aging versus disease" and "aging plus disease," -- that is, distinguish changes due to normal aging from those due to disease and clarify the relationship of aging to the etiology, course, nature, and treatability of different diseases. External (environmental) influences that interact with aging include: I) Nutrition. 2) Drug metabolism. 3) Physical and chemical factors. Because of their importance to biomedical research, special attention must also be given to: l) Experimental model systems for study of aging. 2) Study of human populations. 3) Resources and training needs. Although research in each of these areas is important, we emphasize a few in order to indicate areas of particular need and significance. Further details are available in the full report on biomedical research that has been prepared by the National Advisory Council on Aging and published by the National Institute on Aging (NlA). Mechanisms of Aging In general, physiological functions of an organism tend to decrease and deteriorate with age. Ultimately, this must reflect cellular involvement either within the organism's molecular or biochemical structures or its cellular organelles. Among these may be included DNA (deoxyribonucleic acid), RNA (ribonucleic acid), cell membranes, mito— chondria, lysosomes, ribosomes, nucleus, and nuclear and cytoplasmic interactions. A clear understanding of the changes that occur with age in these cellular structures and processes -- an understanding that we do not have -- is essential to elucidating basic biological phenomena of aging. The cell remains the foundation of biomedical research, and any investigation into its structure, genetics, biochemistry, and physiology must be given priority. Atten- tion should be directed toward those factors which relate to the cell, its genetics, and the effects of experimental or natural alteration in any of its components on the life Span of the cell. Studies of cell function and death are critical in providing a framework to answer the question of whether a loss of cells with age leads to a decline in physio- logical function, or, conversely, decreases in physiological functions result in cell losses. These questions are of great concern in considering the viability of several systems, such as musculoskeletal and connective tissue systems, central nervous system, gastro- intestinal system, and endocrine system. The concept of relating decline in physiological function with advancing years has received little attention, particularly at the systems level. What information is avail- able is of questionable value due to deficiencies in experimental design and failure to engage in effective longitudinal studies. However, the natural next step beyond investi- gations at the cellular level is an appreciation of normal phenomena occurring within organ systems. Among the systems that have specific relevancy to aging are the cardio- vascular, pulmonary, endocrine, and nervous systems. These account for a large propor- tion of death and morbidity within the aging population. The NIA must support research leading to an elaboration of normal aspects of aging in these and other systems so that a reasonable base line may be determined, against which disease processes may be meas- ured under the auspices of disease—oriented institutes within the National Institutes of Health (NIH). Since a basic objective of aging research in general, and gerontological biomedical research in particular, is to effect a significant increase in useful life span, the under- standing of normal components of systems aging should be given high priority. In relation to this, basic research in exercise physiology should be supported to determine whether normally aging systems may be influenced positively to withstand the stresses of aging. If they can, the application of knowledge gained from research in this area could have major results in public health and social terms. It appears that the immune system may be most promising, from both biological and clinical points of view, for the study of the process of aging. The immune system is intimately involved with the body's adaptation to environmental stress and change. Recent studies have established that certain normal functions decline with increasing age and that, associated with the decline, is the rise in immunologically related diseases, including autoimmune diseases, cancer, and antigen-antibody complex diseases. Con- sidering the impact that immunology has had on recent concepts in medicine, it is es- sential that the normal range of immune activity be determined in relation to age and that studies in the restoration of declining normal immune functions be supported. Interaction of Aging and Disease The exponential increase in the death rate with age is necessarily associated with increases in the rate of development of a large number and variety of specific diseases. Indeed, some important diseases occur almost exclusively in the aged. Nevertheless, clinical research on many of these diseases has failed to consider the pathophysiologic changes that take place with aging, changes which so alter the organism that suscepti- bility to disease is remarkably increased. Studies on physiological processes of aging and on the diseases of the aged have often been conducted by two distinct groups of investigators -— physiologists and clini- cians. The physiologic studies are commonly surrounded by an aura of inevitability -- that irreversible, nonpreventable processes are being investigated, that differences found in different age groups or changes found in individuals as they age represent "normal aging." However, indistinguishable changes occurring earlier in life may well be classi- fied as diseases. There has thus arisen an "aging versus disease" dilemma, which is commonly discussed but rarely investigated in depth. Some of the more obvious examples of this problem are the deterioration of glucose tolerance with age versus diabetes mel- litus, the increase in blood pressure with age versus hypertension, and decreases in pul- monary function versus chronic obstructive pulmonary disease. An integral aspect of this problem of aging versus disease is the definition of "normal" used in specific diagnostic tests. Despite the documented decline in function in many organ systems with age, standards of normality rarely take this age factor into account. In addition to the examples cited above, creatinine clearance (a test of kidney function) has had no clear-cut standards established for age. Even where some efforts have been made to take aging into account, studies have been carried out mainly on man, despite well-recognized, major sex differences in many physiological functions. An equally important research problem might be categorized as "age plus disease." The expression of diseases (the symptomatology, physical signs, drug effectiveness and toxicity, prognosis) may differ substantially by age group. The characteristic expression of such diseases as hyperthyroidism and diabetes in youth and in old age may be so dif- ferent that they appear to be totally different diseases. Investigation of the mechanisms of this type of age effect is also a major need. Differences between the very old and the young adult are so spectacular that research comparing these age groups is almost guaranteed to produce large and statisti- cally significant differences. The middle-aged are often neglected in clinical investi- gations; the tacit assumption seems to be that an adult "plateau period" exists. But there is evidence from physiologic studies of many organ systems that decreases in organ function begin in early adult life and are progressive throughout the life span, sometimes (but by no means always) accelerating in very old age. An example of this failure to appreciate the progressive nature of age changes is the recommendation in some text- books of medicine that diagnostic standards for glucose tolerance tests are valid to age 50 but need to be adjusted after that age. Research on the middle-aged must be included if the aged person is to be fully understood. Furthermore, the middle-aged person is biologically different from the young adult and needs to be studied for his own sake. Among the diseases associated with aging, a number should receive high priority, and research on several diseases that are already the focus of programmatic commitments by specialized institutes should be expanded. The NIA is in a unique position to support research emphasizing the role of intrinsic aging in the interaction of aging and disease. While all such processes cannot be named, those of particular clinical significance include senile dementia, cerebrovascular disease, cardiovascular disease, prostatic disease, meno- pause, renal diseases, endocrinopathies, osteoporosis, osteoarthritis, chronic lymphatic leukemia, breast cancer, hematologic disease, and response to infection. External Influences and Aging Nutrition appears to affect aging, as well as exerting profound effects upon growth and development. While early dietary practices may affect longevity, the adult diet emerges as a factor in such age-related diseases as artherosclerosis, diabetes, and biliary tract disease. Until more basic information regarding nutrient metabolism with age is obtained, there will be no rational basis for nutritional recommendations for the elder— ly. This is a critical area since so many government—supported programs relate to nutri- tion in the older age group. Resources and Training Needs Among other areas that require special attention because of a critical relation- ship to biomedical research, development of programs to support resources and training needs should be given immediate and high priority. Centers. Because of the complex subject matter of gerontology the individual gerontologist working independently in his laboratory is at a disadvantage. Gerontology is of only peripheral interest to his parent institution, the enormous expense of main— taining appropriate resources and of providing proper training for pre- and postdoctoral personnel is, at best, extremely difficult to overcome, and the opportunities for colla— boration between laboratories are minimal. Furthermore, the opportunity for researchers in aging to be inspired by the work of highly regarded investigators in related fields is also held to a minimum. Regional centers for biomedical research on aging should be organized so that the multidisciplinary talent needed to investigate this problem can be utilized most effectively. The objectives of such centers should be to centralize talent, to provide the accessibility to unique resources, and to offer the mechanism for relevant training. Resources. There are three general categories of resources, any one or more of which could exist in its own right or provide the basis for appropriate research pro- grams as part of a center. One such resource consists of geriatric human populations. Mechanisms should be developed so that such populations can be encouraged to parti- cipate in programs of gerontologic research. For example, many public and private hospitals, nursing homes, and homes for the aged would undoubtedly be interested in and available for collaborative studies with researchers in the field of aging. In addition, a patient population with specific age-associated diseases is needed for medical-school or hospital-based research. Cohorts of normal subjects are needed 5 for long-term, multidisciplinary studies of aging. Cross—sectional studies, although faster and easier to conduct, may provide misleading information. Differences among age groups may not be attributable to aging m E, but to cohort differences, environmental changes, or survivor artefacts, whereby a select group of subjects survive. The availa- bility of corps of healthy volunteers covering the entire adult span of life would provide a valuable and continuing resource. Just as the unavailability of aging experimental animals has hindered progress in biological gerontology, difficulties in recruiting human volunteers has inhibited clinical gerontology. The multidisciplinary approach, especially in the study of human aging, is essen- tial to answer certain types of questions. For example, recent studies on alcohol and aging required the collaboration of clinical gerontologists, physiologists, pharmacolo— gists, biomathematicians, and experimental psychologists in order to design a study on the distribution kinetics, metabolism, and effects of alcohol in man. Another example of the need for a multidisciplinary study team and of the longitudinal research strategy is the need to understand the mechanism underlying the rise and fall of serum cholesterol from the early to middle to late adult years. The interactions of such factors as obesity, inactivity, dietary habits, and decline in glucose tolerance and attendant endocrine alter- ations in these age changes need clarification. ' In addition to population studies, studies in depth using representative research subjects can best be carried out in specialized facilities, such as the existing Clinical Research Centers. For purposes of aging research using human subjects, support for the maintenance of a viable Clinical Research Center program should be encouraged. A second general category of resources needed for aging research is colonies of experimental animals, the most popular of which are rats and mice. Largely through NlA efforts, it was established that colonies of aging rodents can be maintained reliably and reproducibly into healthy old age in an appropriate commercial facility; they can then be shipped to various investigators. However, the enormous cost cannot be met by most researchers. For example, there currenty are only two NIH-supported, com- mercially maintained colonies in the extramural program. These animals, plus the intra- mural colonies, are not sufficient to meet the demands either of investigators already committed to aging research or of those who have proposed relevant pilot experiments. Clearly, there is an urgent need to establish regional animal distribution centers if feder- al agencies hope to catch up with the interest in aging research generated in the last five years. In addition, support for the existing specialized nonhuman primate centers needs to be encouraged and developed, since aging monkeys bred in these colonies provide a valuable resource. Distribution and availability of cellular models (such as standard fibroblast cells), although as expensive as animal models, have progressed further. However, two new directions of aging research based on cellular models must be recognized. One of these is the establishment of biochemical features that are intrinsic to cells derived from species of different life spans. The other concerns establishing banks of cells from indi— viduals afflicted with genetic diseases related to premature aging, such as Werner's syndrome and progeria. These two new areas of work should inspire a further burst of interest in gerontological research. Resources must be available to meet the demand. Training in biological aspects of aging. There are but a handful of highly regarded courses or lecture series on the biology of aging in the United States. These programs neither meet the current degree of national interest in the biology of aging nor provide adequate, well-rounded training for pre- and postdoctoral students who desire to enter the field. There is almost no mechanism for the established investigator outside of geron- tology to focus his research on problems of aging and to consult with investigators in gerontology, except for sabbatical leave or a fortuitous relationship with someone cur- rently involved in aging research. The rapidly growing interest in aging research outside of gerontological circles is evidenced by two symposia held by the American Association for the Advancement of Science on biological aspects of aging during the past three years, a feature conference in the biology of development and aging at the annual meet- ing of the Federation of American Societies for Experimental Biology two years ago, and the fact that the I976 Gordon Research Conference on the biology of aging received applications from more than twice the number of people that could be accepted, many of them from people new to the field. In order to meet this increasing demand, the following recommendations should be considered: (i) the availability of training grants related to basic research on the biology of aging, including laboratory work, formal courses, and lecture series or sym- posia; (ii) availability of pre- and postdoctoral fellowships specifically designated for study of the biology of aging; (iii) availability of career-development awards and special fellowships designated specifically for study of the biology of aging; and (iv) continuation of the NIA intramurally sponsored summer courses on the biology of aging and the patho— biology of aging. Training in clinical aspects of aging. The research needs in clinical gerontology can be met only by developing new training programs. Biomedical research efforts on man must, of course, involve physician-scientists. The physician half of this dual person- ality may be a practitioner in any of the recognized specialty and subspecialty areas, but there is a need for internists who are specifically interested and trained in the prob- lems of the aged -- that, the geriatrician or the clinical gerontologist. The one million long-term care beds in the United States, occupied almost completely by the elderly, are matched by only two formalized training programs in geriatric medicine. There are very few centers that offer training for research in clinical gerontology. This discrepancy between need and supply is especially critical now, since an increasing number of medical schools, veterans' hospitals, and research centers are searching for persons to establish new, coordinated programs of aging research. The innovative train- ing efforts needed might involve, for example, a five-year postgraduate program of internal medicine emphasizing geriatrics, clinical gerontologic research, and didactic work in a school of public health. In addition to these postgraduate (or post-MD.) programs, clinical gerontology should be introduced into the curricula of the health schools -- medicine, dentistry, nursing, and allied health programs. There is evidence that, as students progress through school, their interest in the aged declines. The reasons for this are in themselves subject to research so that corrective steps may be taken. The training of basic investigators and clinicians has been discussed separately to emphasize the special needs of each group; however, there must be constant and ready dialogue between the two groups for truly significant advances in aging research to occur. The researcher gains on understanding of real, as distinct from theoretical, prob- lems encountered in clinical medicine; the clinician, beset by day—to—day concerns in treating patients, is made aware of new advances of possible significance to him. It is through this mutual reinforcement by highly skilled professionals interested in the same goal but taking different routes that we will begin to understand and effectively treat many of the problems that plague the aged. Behavioral and Social Sciences Research Long life expectancy is a decidedly modern achievement. While the total popu- lation of the United States increased 2.5 times from I900 to I970, the number of persons ages 65 and above increased 7 times. This trend is expected to continue. Persons age 65 and over now constitute about ten percent of the total population (about 22 million). Over the next 50 years, the pro- portion is expected to be between l2 and I6 percent. lf zero population growth is reached within the next 50 or 60 years, there would be one person over 65 for every |.5 persons under 20; the ratio is now one to four. About one-third of the older population is very old, 75 years or above. This propor- tion will stay about the same for the foreseeable future if mortality rates remain con- stant. If they do, there will be about l2 million very old persons by the year 2000. If mortality rates decline, however, the number of very old persons may be as high as l6 or [8 million. A 65-year-old man can now expect, on the average, to live to 78; a woman of 65, to the age of 82. By the year 2000, life expectancies for 65—year-olds may increase by another two to five years. The gain in life expectancy during the twentieth century represents an achievement for modern industrialized societies, but it brings with it substantial changes in the society as a whole and enormous challenges for policy-makers. ln oversimplified terms, policy- makers must consider two different sets of issues. One set arises from the fact that there are increasing numbers of the "young-old" persons in the late 50‘s, the 60's, and the early 70's who are retired, who are relatively healthy and vigorous, who seek for meaningful ways to use their time (either in self-fulfillment or in community participa- tion), and who represent a great resource of talent for society. The second set of issues stems from the fact that there are even more dramatic increases in numbers of the "old-old" persons in the mid-70's, the 80's, and the 90‘s. In this category, an increasing minority remain vigorous and active, but a majority need a range of supportive and restorative health and social services. The old—old of the l970's also represent a disproportionately disadvantaged group. The reasons are several, including the fact that this population group contains immigrants who came in the early twentieth century, who were largely uneducated and unskilled, and who survived by taking jobs that established persons in American society did not want. Large numbers of adults suffered traumas during the depression from which many never fully recovered; and many did not build up sufficient equity in the social security system during their earning lifetime to adequately sustain them through decades of retirement. Future cohorts of the young-old and old-old will have different characteristics. They will have been better educated, will have received better medical care, and will Chair: Bernice L. Neugarten, Ph.D., The University of Chicago, Chicago, Illinois. Co-chair: George L. Maddox, Ph.D., The Duke University Medical Center, Durham, North Carolina. have been provided the now common benefits of the social security system. Their life experiences will have been markedly different from earlier cohorts of elderly persons; consequently, their expectations of life, including old age, will be different. The point is that programs suited to the young-old and old-old populations of today may not -- and probably will not -- apply to future cohorts. Our planning must take this into account. We need, moreover, to understand the effects of the aging society on all our social institutions: family, community, labor force, educational, political, and economic. The needs for both basic and applied research in the behavioral and social sciences will become ever more pressing if we are to formulate enlightened social policies for both the old and the young, policies that are adequate both for the present and for the future. The State of Knowledge Some observers as early as the l930's studied demographic projections and foresaw that the growth of the aged population would bring with it widespread changes in family structures, in housing, in patterns of work and retirement, and in needs for health and social services. But it was not until the I950's that a significant number of scientists 't began systematic studies of behavioral and social aspects of aging as a set of complex scientific problems. We do not yet have powerful theories in psychology, sociology, anthropology, economics, or political science to explain the behavior of the aging individual or changes in the aging society. Nevertheless, a number of generalizations based on research findings over the past two decades now seem warranted. Some of these generalizations have important theoretical implications for future research, as well as important practical implications for policy decisions. For example: ‘ |) Chronological age in the second half of life is demonstrably related to increas- ing risk of decrement, morbidity, and mortality. Cross-sectional studies (those in which I persons of different ages are compared) appear to exaggerate the decrements with age; but longitudinal studies (those in which the same persons are followed over time) may underestimate them. Selective attrition in samples used in longitudinal studies compli- cates the interpretation of findings. The best available data show, however, that the large majority of older persons followed over time do not decline markedly in intellectual and social competence until very advanced old age. Many social and psychological func- tions hold up well beyond the age of 70, although some functions may decline as early as middle age. Intellectual functioning is a case in point. Some of the observed declines in old age are probably more attributable to poor health, social isolation, poverty, limited .. education, and lowered motivation than to processes intrinsically related to aging. Where declines do appear, they occur primarily in tasks in which speed of response and integra- tive processes such as reasoning are critical. At least some of these declines can be . compensated for by appropriate teaching methods. ‘ 2) The social integration of the great majority of older persons has been demon- strated in every society that has been systematically studied: That is, most young-old l0 persons are engaged in a wide range of social roles and are active participants in the community, and most old-old persons are not isolated from family, from friends, or from neighborhood networks. At the same time, social isolation, age segregation, and inade- quate social participation characterize substantial numbers of older persons, particularly the very old, in our own and other societies. 3) Neither the experience of crisis nor the response to it is uniform among older persons. This has been repeatedly demonstrated by research on life transitions and on k crises of late life often associated with physical and psychological deficits or with the loss or modification of central life roles. Deleterious effects that do occur seem to be significantly modified by the timing of the event in the life cycle, by earlier styles of coping behavior, and by the social resources available to the individual. It has become clear that chronological age age is a relatively weak predictor of adaptation patterns. 4) Illness and disease often occur in individuals who have experienced a series of psychologically stressful events, a fact particularly pertinent to an understanding of illness in old age. It appears to be the stressful events, not age a E, that are the critical factors. To the extent that the effects of such events can be ameliorated by education, counseling, and the provision of various intervention programs that provide social supports, patterns of aging can be altered and improved. 5) Studies of development in late life, and studies of development generally, have shown the importance of environmental variables and personality characteristics in understanding behavior. In many instances, it appears that environmental variables that have influenced the individual early in the life cycle are of major importance in later life; for example, level of formal education is related to social and psychological com- petence in old age. We need to know a great deal more, therefore, about the signifi- cance of both environmental and personality factors as they affect physical and mental health in old age, and we need to know more about how to measure such factors. In parti- cular we need to distinguish age changes from age differences. With improved methods and data sources, investigators can now begin to pinpoint which of the differences be- tween younger and older persons are attributable to the effects of aging (maturation) and which are attributable to differences between cohorts (groups of persons who were born at different points in history and who therefore have had different life experiences). 6) Among members of a birth cohort, variability in biological, psychological, and social characteristics does not decrease with chronological age, at least not until the very end of life. Related to this fact, there are multiple life-styles and multiple patterns of successful aging. One important implication is that, if we are to improve the quality of life for older persons, public policies should provide a wide range of options with regard to housing and living arrangements; opportunities for work, education, and leisure; and health services and social services. 7) There is a positive, but not exact, relationship between the physiological state and the social competence of the individual. The extent and nature of this relationship is not yet clear, nor is the possibility that changes in both physiological state and be- havior stem from some underlying set of processes (for example, genetic factors or social factors). ./ 8) Modern industrial society has the resources to maintain adequate income for older persons and to finance essential services for those who need them. The willingness to allocate resources in behalf of older persons is primarily a sociopolitical issue involv- ing cultural values, national priorities, and principles of equity. While competing claims of different age groups for scarce social resources have not yet led to conflict, they might do so in the future. 9) Social and professional concerns with death and dying have increased in recent years, partly because the process of dying can be partially controlled by modern tech- nology. These concerns have been based upon personal and humanistic insights and have prompted various clinical, educational, and research programs designed to assist seri- ously impaired and dying individuals and their families. Associated with these concerns are the emerging medical, legal, and ethical issues regarding the definition of life and the prolongation of life by technological means. Research Support Except for minimal investments by private foundations in past years, research in adult development and aging has been largely dependent on federal support. In recent years, NIH has been the most important single source, including the Adult Development and Aging Branch, which was formerly part of the National Institute of Child Health and Human Development and which in I975 was incorporated into the NlA. In large part, NIH support generally, and NlA resources specifically, have been directed toward bio- medical research. Agencies such as the National Institute of Mental Health, the Social Security Administration, the Department of Housing and Urban Development, the Veterans Administration, and the Administration on Aging have contributed to behavioral and social research on aging, but the contributions of these agencies have tended to empha- size primarily applied and policy-related research and evaluation. As the problems of our aging society become more apparent, both basic and applied research need to be expanded; and both biomedical and social-behavioral scientists need to be encouraged to turn their attention to this field. Research Areas of Greatest Promise and Need I) Dependency -- social, economic, and physical -- is a major problem for the very old and for the young who care for them. Research is needed on how such depend- ency can be reduced and prevented. The problem is complex, and should be approached from several perspectives. Increasing numbers of older people are retiring from productive roles in the work force, in spite of demonstrated competence to remain productive. If the numbers of older people continue to increase, and if the growth rate of the total population con— tinues to decrease (as a result of declining birthrates), the cost of public income— maintenance programs for retired persons will probably rise, particularly in the decades after the year 2000. Research should be directed, therefore, to the development of accurate demographic projections of the population and of the work force. A related need is research on the development of forecasts of the costs of income-maintenance l2 programs; health, housing, and welfare services; and tax rates on individual and corpor- ate income. One research priority is to develop appropriate models for simulating the economic and social outcomes of alternative arrangements for the provision of income and services. Such studies will help clarify alternative social policy options with regard to the social and economic welfare of older people. Societal concern is growing about age discrimination in employment and in other social opportunities. Functional criteria of competence, particularly work competence, need to be developed, as do programs aimed at demonstrating how those individuals who wish to remain economically productive can do so. Moreover, research is needed on how the conditions of work may be reorganized toward the same goal. Particularly important are studies of values and attitudes of both young and old persons with regard to work and leisure. Research is needed on the factors involved in an individual's decision to retire, on the retirement process, and on the effects of retirement patterns on the wide society. Studies should be focused on such factors as health, economic status, personal prefer- ence for work and leisure, and social and economic constraints on labor force participa- tion. Studies are also needed on the social, economic, and political effects of retire- ment on society. There is insufficient understanding of the cumulative impact of earlier life ex- V perience on the situation of the aged. Many problems that today are regarded as inherent problems of aging may actually be problems of the particular cohorts who constitute the present aged population. Thus, studies are needed that encompass the whole period of adulthood and late life. An obvious example is the impact of lifetime earnings on the economic status of the aged; another is the changing pattern of work and leisure over the adult life span. There are also more subtle influences of earlier adult experi- ence: life crises and their management, the intermeshing of different social roles (in family, occupation, and community), the changing value patterns among the young and the old, their changing expectations with regard to the effects of aging, and the effect of negative stereotypes of aging on both young and old. 2) An individual's social competence is related to the degree to which he or she is integrated into the social life of the family and the community. What needs further exploration are those specific personality, social, cultural, and environmental factors that produce social competence and personal satisfaction in late life. Attention should be directed toward differences in attitudes and behavior between men and women, and toward subcultural variations, such as those based on race, ethnicity, and social class. Anthropological research on patterns of aging in other cultures should also be encouraged, particularly in traditional societies, which are fast disappearing. Such studies will help clarify the significance of cultural values in influencing processes and patterns of aging; they will help to distinguish those psychological and social changes of aging that are common across cultures from those changes specific to our own culture. 3) Special attention should be given to research on family and kinship networks. Specifically, research is needed on intergenerational relationships, on the changing roles of women, on how family networks may be changing as social resources for the older l3 person, and on the role of the family in maintaining the old-old person as a member of the communtiy. Such knowledge is critical in developing policies aimed at reducing the unnecessary institutionalization of older persons. 4) Research is needed on the relationships among psychological, social, and physi- cal aspects of health in middle and late life and on how health is related to socioeconomic status, ethnicity, rural-urban residence, and other social factors. Investigators are giving increased attention to stress, its correlates and its consequences, and to factors that ameliorate negative consequences. The relationships among life satisfaction, illness status, perception of illness, and self-concepts should be studied. Reactions to bereavement also need further study. Although most persons adapt reasonably well to such life events as retirement and widowhood, many do not. For example, there is evidence that widowhood is associated with high rates of morbidity. Little is known about the causal relationship between physical and psychological changes in widowhood or about the effectiveness of intervention programs. Research should also be addressed to the effectiveness with which older persons utilize health services and related social services, and to how such utilization can be improved. 5) The life expectancy of women is considerably greater than that of men. Basic research is required in the behavioral and social, as well as in the biomedical, sciences to understand the observed differences and to improve the life expectancy of men. The different life-styles of men and women, the different stresses to which they are exposed, and other social factors that contribute to the greater morbidity and mortality of men must be investigated. 6) Careful studies should be made of what has been learned from "natural" social experiments, Such as the Medicare and Medicaid programs, and their effects upon older persons, upon families, and upon the health care system. Parallel with such surveys, there should be limited social experiments with regard to the effects of (i) flexible or phased retirement; (ii) the creation of community-wide service corps of older persons; (iii) new educational opportunities for older persons, including not only the role of edu— cation in second careers and in meaningful leisure pursuits, but also the role of health education for self-care in old age; (iv) alternate forms of social and health services systems; and (v) effects of alternative physical and social environments on the well-being of older persons, including housing arrangements and the environments of long-term care institutions. 7) With regard to the problems of dependency in old age, we need particularly to understand how impairment is translated into functional disability, what social and biomedical factors are involved, and how the intellectual competence that is character- istic of middle age can be maintained. Many aged persons show deterioration in their abilities to perceive and respond appropriately to environmental stimuli, abilities that are crucial to maintaining personal competence. Thus, studies are needed of stability and change in cognitive functioning, including memory, learning, intelligence, and perception, and of the physiological and Ill psychosocial variables involved. Decrements associated with aging processes must be distinguished from decrements associated with environmental or disease factors; and factors that are subject to direct intervention should be identified. Experimental studies are needed, not only to clarify age—related changes in per- formance, but also to assess procedures designed to compensate for observed deficits. Animal models may be particularly useful in developing hypotheses to be confirmed in studies of human behavior. Research is needed on the psychopathologies of advanced old age and on the be- havioral and psychophysiologic, as well as neuropathologic, factors involved. Such studies are now in the forefront of scientific activity and are likely to produce important find- ings soon. Behavioral and medical interventions directed at the maintenance of intellectual functioning and at the prevention of the organic brain syndromes, or senile dementias, should receive high priority. Research of these types may be expected to stimulate the development of a clinical psychology and psychiatry of late life. 8) Studies should be carried out on the effects of various governmental and non- governmental policies upon aging and the aged: For example, how do policies directed toward other age groups affect the aged, and vice versa? What is the effect of manpower and training programs on the employment of older persons? How do macroeconomic policies designed to stimulate the economy or to restrain inflation affect retirees? What are the effects on older persons, their families, and their communities of governmental policies related to housing, transportation, health care, and retirement? As the numbers of older persons increase, and as successive cohorts show different characteristics, re- search of this kind will be particularly important with regard to city, regional, and national planning in the next two decades. Research Training Research training in the field of aging is a critical need. The number of trained personnel with career commitments to research in aging is very small. Individuals should be attracted from adjacent fields, through such mechanisms as postdoctoral and other special training opportunities; and greatly increased numbers of students should be trained at predoctoral levels, both in single disciplines, where aging can form an area of special- ization, and in interdisciplinary graduate programs focused directly upon aging. Perhaps an overly modest goal would be to increase the number of competent researchers in the next ten years by at least the same proportion as the increase in numbers of persons age 85 and over in the population -- that is, by nearly 50 percent. Research on Human Services and Delivery Systems The primary focus in this area of research is on methods for organizing and de- livering services to people to assure availability and quality of care. Research on human services and delivery systems overlaps the biomedical and behavioral-social fields, which produce the knowledge directly or indirectly applicable to the provision of services to the aging and aged. This third sector of research is needed as a bridge between the bio- medical-behavioral-social findings and the actual provision of services. It concerns itself primarily with measuring the magnitude of service needs in populations, the corre- sponding needs for and availability of the manpower and facility resources to meet those needs, the manner and extent of use of those resources, the ways in which service systems are organized and function, the kinds and content of services received, their quality and cost, and their outcomes in terms of people's well-being. Research on human services and delivery systems is naturally oriented to practice settings and applications. Within this orientation, however, it encompasses 'both basic and applied research. It deals with all aspects of living: health, nutrition and food serv- ice, physical living environments, employment and other economic supports, the com- mercial marketplace, transportation, communication, social services, legal and physical protection, education, participation in the community, and spiritual well-being. Pioneering research work has been done or is underway in the various content areas of human services. Study of options for providing continuity and coordination of services, including preventive and rehabilitative care and methods for organizing and financing services and service delivery systems, is needed to bring practical benefits to older Americans. Current State-of-the-Art An examination of public and private programs aimed at human betterment has shown that some of these programs fail because historical factors and culturally deter— mined attitudes, beliefs, and values are not adequately studied or understood. Research has not yet given us adequate knowledge to design appropriate service organization and delivery. Health The organization of health resources tends to be mismatched with the patterns of illness and disability among older persons. Health care tends to concentrate on the specialized management of acute, episodic disease in hospital settings, which, in turn, are not linked with community—based primary, preventive, or rehabilitative care. This mismatch has become increasingly obvious, as in Medicare. The escalating cost of health Chair: Paul A. L. Haber, M.D., Veterans Administration, Washington, D.C. l6 care for older persons underlies a general, widespread sense of urgency in devising more efficient and effective health care systems. However, little is known beyond survey data regarding how well Medicare and Medicaid programs serve the needs of older persons (particularly subgroups within the aged population). It is not known what impact these programs might have on financing should they be expanded to include those related serv- ices necessary to sustain people in their homes or communities. Assuming that some sort of national health insurance plan will be enacted, research is needed to help design it. Although only a minority of older people are free from chronic disease, the great majority continue to function in the community. The emphasis on avoiding institutional- ization and on keeping frail and sick people in the community assumes, inappropriately in many instances, the availability of a family and community service that can be mobi- lized to care for the older person. The aging require a variety of preventive health and social measures. The enhance- ment of their functional capacities must be one of the main goals of health care. Re- search and development in prosthetic devices, for example, must be matched with dis- semination, in which research also plays a role. Paramount in research on health services delivery for the aging is the need for breaking new ground in both disease prevention and rehabilitation. Cost—benefit studies in both areas must be mounted, to be sure, but of even greater importance is the realization that prevention of after effects of disease may be of prime value. With respect to rehabilitation, again cost—benefit studies are important, but there is also great need for studies relating to motivation and dependency- creating programs. Some persons living outside of institutions require home care, which, to a substantial degree, is provided by relatives. Such care has been treated as though it has no economic cost, even though the cost of publicly financed home health care programs is demonstrably high. Inappropriate placement of older persons in institutions reflects medical custom and the unavailability of other services and facilities, rather than a careful decision on the part of the older person or his family. Where home care programs are limited, institutionalization of an older person is often the only option available. Resurgent interest in family care of the aged is in part an emotional reaction to long-term care institutions and their negative connotations and in part a search for cheaper alternatives to the cost of institutional care. Approximately five percent of the persons age 65 and older in the United States are in long-term care institutions, and another ten percent are considered very likely candidates for institutional care. Though excellent care is provided in many institutions, the long—term care industry has been seriously criticized. Long—term care facilities are all too often isolated from the more extensive backup services of hospitals, from community-based programs, and from major professional schools. Studies of utilization patterns of long—term care facilities have indicated that availability and utilization of services tend to follow changes in reimbursement mechanisms. Mental Health. Available data reveal that mental health care resources are in- sufficient to meet the needs of the rapidly expanding older population. At least l5 per— cent of the population age 65 and older are in need of mental health treatment and are l7 responsive to appropriate treatment techniques. Communtiy—based treatment centers, where they do exist, treat approximately two to three percent of those in need of care. Research is needed on whether mental health problems among the aged would be treated more or less efficiently if such programs were integrated into a comprehensive health service system. Studies have shown that the provision of comprehensive community mental health services can substantially reduce the number of older people admitted to state mental hospitals; when institutionalized elderly patients are offered modern treatment programs, a significant proportion of them can be rehabilitated and discharged from the institution; and the provision of individualized treatment and activity programs can substantially increase the well-being of old people who remain in institutions. Nutrition and Food Service. Studies of food consumption and nutritional status have indicated that the elderly eat less as they grow older and that their diets are fre- quently low in minerals and vitamins. The reasons have been cited as economic, lack of motivation, loss of mobility, changing health status, lack of information, food fads and quackery, and long—standing food habits. Further studies of services to improve the diet of older people are needed and might best be pursued as a component of broader investigations of delivery systems for health and social services. Research in nutrition services has generally taken two forms: (i) efforts to de— scribe and define nutrition problems of a specific population; and (ii) demonstration mod- els for delivering nutrition services or testing new approaches. Anthropometric, bio- chemical, and clinical measures have been found to be effective and acceptable accompa- niments of survey techniques; they may even enhance the acceptability of follow-up evaluation (a question that bears investigation since policy-makers are increasingly weighing costs of services against benefits). Demonstration models in nutrition services for the elderly have been largely descriptive in nature, testing feasibility and determining costs. The major effort has been in relation to individual, home-delivered and group meals programs. As these pro- grams move from the demonstration phase into established community services, research needs shift to questions of their appropriate utilization, manpower and training needs, quality controls, and impact on the client and the community. Other research is test- ing the effectiveness of various techniques to change the food habits of the elderly. As part of preventive health services, models should be developed to test ways of incorporating more extensive nutritional counseling into health maintenance services. Nutritional assessments could be built into preretirement counseling, health screening programs, and industrial health services. Assessment methodologies, training needs, reimbursement mechanisms, utilization and referral patterns, and impact on client use of other health services should be explored. Policy questions regarding public funding of home support services as alterna- tives to institutional care demand early answers. Research should focus on packages of services based on the needs of clients, considering shopping assistance, home-delivered meals, homemaker services, and nutritional counseling. I8 Finally, there is a need to evaluate nutrition services in institutions that care for the elderly. New techniques for monitoring the nutritional status of patients in hospitals, as well as in skilled nursing facilities, should be applied, along with well- d designed studies to establish standards applicable to the aged and to evaluate the costs of routine monitoring in long—term care settings. Models are needed to demonstrate nutritional rehabilitation programs, to measure their impact on patients' mental and physical functioning, and to identify appropriate staffing patterns and training needs. Dental Health. Related to nutrition, with additional implications for general health and social well-being, are the twin problems of loss of natural teeth and greater need for dental care with advancing age. Further complications arise out of the im- portance of bringing dental health care to the patient who is homebound, institution- alized, or otherwise lacking in mobility. Even existing health care systems and reim— bursement procedures rarely provide for dental coverage. Part of the problem of using mobile equipment to deliver dental care seems to be resistance by the dental profession. The major strengths of the health care system in the United States are its di- versity and high degree of specialization. In terms of the needs of older persons, how- ever, the diversity and specialization entail some loss in treating the individual holisti- cally. Consequently, emphasis has been placed on comprehensive, integrated service delivery systems. But research is needed to determine the actual effectiveness of in- tegration: What degree of integration is desirable? In what forms? What impact will different forms of integration have on the dependence or independence of older persons? What resources will be needed? What cost mechanisms (cost sharing, third-party pay- ment, and so on) would be most effective? Physical Environment Physical environments may either enhance and complement the quality of life for older people or restrict their opportunities for maximum independence and satis- faction. There is evidence that, for most Americans, old age is a time when choice be— comes constricted, the environment narrows, and functional decrements press more and more with each passing year. Reduced morbidity and mortality are associated with housing built, especially for the elderly. The needs and conditions of older persons are multifaceted -- housing needs are linked to health status and conditions, and both, in turn, may be directly related to income. Service interventions, therefore, require linkage between medical, health, social, environmental, and other services. However, research and social experiments are needed to determine what services should be part of the housing environment or of accessible, "one-stop" centers. Transportation Transportation is often the factor in the physical environment that links the elderly person to the services, facilities, resources, and opportunities necessary for his existence. Studies of transportation systems indicate that the elderly depend on walking, which is limited by inadequate pedestrian accommodations and security. Studies also indicate that transportation is least adequate for the groups who need it most -- the physically l9 frail, persons without relatives, minorities, inner-city dwellers, and the poor. Older persons have been shown to prefer adequate transportation to the clinic or hospital of their choice over moving to be near a facility. The decline in ownership of automobiles in the older age groups is mostly a re— flection of their income situation, but it is also influenced by decline in physical, psycho- logical, and motor skills. This problem will become even more serious as automobile- oriented suburban populations age. The need for improved transportation has been documented. So has the need for living environments that include services, facilities, and so forth. Still needed are re- search and social experiments to formulate and test other means of linking people and services (that is, home-delivered services of all types and new technologies). Communication Just as transportation links people to services and facilities, communication and information are essential to older persons in need of services. Research has shown that over half the services provided to clients by public social services are information ex— changes of one sort or another; hence, some may be directly amenable to enhancement by telecommunication. For the present aged, traditional face—to-face communication is very important, but this does not mean that other media are necessarily inferior. Symbolic transaction is not the sole component of human communication -- hosts of nonverbal or nonsymbolic signs and signals round out human communication. Research is needed to determine what mix of media can meet the communication needs of the elderly. Social Services A limited range of social services was made available with the passage of social security legislation. However, implementation of social services for the aged has re- ceived low priority. This is reflected in the limited interest of research, education, and training to develop and apply the knowledge required for service intervention and in the inadequate funding of both research and services. Legislative attempts to increase the development of social services through reve- nue sharing and the new Title XX have not yet produced much. Research is needed to determine what social services are already available at the state and local levels, what additional services are needed, why states have not utilized revenue—sharing funds on behalf of the elderly, and whether revenue sharing or other alternatives are needed to increase or improve social services for the elderly. Legal Services Older persons are frequently unable to negotiate the bureaucratic maze of eligi— gibility and entitlements; their personal freedom and control of property are subject 20 to vagaries of the laws of guardianship, conservatorship, and involuntary commitment; and they are frequently the victims of crimes. Congressional investigations of fraud and quackery, credit problems, and the like illustrate the negative approach to the older person as consumer. In the quest for adequate and effective legal assistance to the elderly, two types of research are needed: (i) basic research into existing statutes and laws relating to guardianship, conservatorship, and so on and (ii) demonstrations that address problems of entitlements. Commerce Among the many issues affecting the availability, adequacy, and utilization of services are those related to the mix of income and service strategies and to the develop- ment of service standards and licensure. It has been suggested that, if older persons were to receive sufficient incomes, the marketplace would respond to their needs by providing services. The marketplace shows comparatively little recognition of the older population, and, where it does, it is concentrated in a few fields such as health insurance, life and annuity insurance, banking services, travel, and housing. But most of these ef- forts have been directed at the more affluent aged. Recent and more rapid growth has been in the health core fields (health services, drugs, nursing homes), where there is major subsidization from the public sector. The remainder of the commercial marketplace has failed to recognize the possi- bilities of the older market in terms of the design of consumer products (clothing, furni- ture, and so on) in which research can play an important guiding role. Education There are two issues in the area of education: (i) education for improving the delivery of human services to the aged and (ii) education throughout life as a human service to society. The first addresses the education of professionals and practitioners working for or with the aged. The second focuses on the ideal of continuing human de- velopment through the process of lifelong learning. There is widespread documentation of the failure of the professions and the serv— ices to respond to the health, environmental, and psychosocial needs of the aging. The trend toward narrow technical and professional expertise and research needs to be halted. Greater emphasis needs to be placed on the whole person, on quality and continuity of care, and less on fragmented services. There are a variety of questions that research should address. For example: Should gerontologic subject matter be introduced as a specialized subject area or be integrated into more generic subject matter? Should exposure be early or late in the edu- cation sequence, or in what combination? What mix of practical and didactic training is most effective? These kinds of questions apply across the board to all professions 2| and disciplines —- nursing, medicine, social work, aides. There is a need to develop and test models for educating a variety of professionals and allied service personnel. The main characteristic of research on adult education seems to be that there is so little of it. Review of literature and research articles reveal three general types of information: (i) "think" pieces reflecting policy and program development issues, as well as broad overviews of adult, lifelong, and continuing education needs and accom- plishments; (ii) reports of successful —- although typically idiosyncratic —- case histories and individual programs; and (iii) demographic survey reports of people, programs, needs, accomplishments, and so forth. The Future Shock syndrome of rapid obsolescence com- bined with increasing amounts of leisure time has been reflected in the quantity and availability of continuing, avocational, and activity courses and programs. In addition to continuing and avocational education, more attention must be focus- ed on health education and consumer education. Lacking in all these areas are research efforts to develop appropriate training materials and social experiments to test the impact of training. Social-Emotional Services Maintenance of health in old age requires, in addition to essential economic and social services, sufficient recreational, educational, spiritual, vocational, and com- munity service opportunities to assure a satisfying life. Retirement has become an accepted pattern in present-day society. This stage of life, with its extended nonwork use of time, has created new organizational arrangements -- that is, senior centers, spe- cial residential living arrangements, new components of social services, adult educa- tion for lifelong learning, and recreational, voluntary, and civic activities. The premise underlying attention to recreational, cultural, spiritual, and leisure activities is that they have important effects on a persons's well—being, sense of self—esteem, and mental and physical alertness. Published materials are of uneven quality, although there is a miscellany of studies that are suggestive and useful. The individual's valuation of work and leisure relative to each other is more attributable to his personality and sense of accomplishment than to economic need and hardship. Thus, some people view leisure and recreational acti— vities negatively, regarding them as frivolous. Accessibility to or convenience to public parks, movies, and sports events has been judged to be far lower for the old than for the young because of such factors as lower income, health problems, fear of crime, and transportation problems. While some service programs have been developed and some demonstrations funded, relatively little research has been conducted in these areas, either because of low priority or because of limited resources. Yet the significance of these services increases, parti— cularly with the growing number of older persons spending more years in nonwork. Re- search needs to identify ways to ease the transition from work years into retirement, emphasizing (i) continuity rather than crisis—oriented provision of services and (ii) the special problems of women. Economic Support While we search for the most appropriate combination of programs to provide quality care at the lowest cost, we must decide how these costs —— whatever they turn out to be —— will be financed. The social security system remains the major source of retirement income, replacing an estimated one—third to one-half of preretirement earn— ings. Private pension plans cover a minority of employees and fewer still retirees. Supplemental Security Income seems to be an improvement over Old Age Assistance, but little is known about why the projected increases in beneficiaries did not material— ize, in view of the number of older persons living below the poverty threshold. Medicare, providing third-party payment of certain health costs, has obviously helped but is playing a decreasing role and seems to be most inadequate in the most serious area —— long-term care. Supplemental private health insurance still plays a minor role. Except for economists in a few federal agencies (Social Security Administration and Census Bureau), there is little activity in the study of the economics of aging. Much can be learned by studying foreign social security systems and experiences. Study of the impact of growing early retirement, retirement income as a proportion of income just prior to retirement, and projections of future retirement income levels and adequacy are among priority research questions. These issues in the economic sphere cry out for policy research that would take into account the significant demographic changes taking place, inflationary pressures, economic growth patterns, trends in benefit levels, equity, and national priorities. Systematic Data Needs The major difficulty in the study of human services and delivery systems is the lack of an adequate data base, both within and surrounding the service systems. While we know that services exist in most communities, we have inadequate information con— cerning the extent of such services, particularly in rural areas. Basic knowledge is need- ed —— what services exist, their adequacy, the gaps in services, the population groups and subgroups utilizing the services, and the extent to which services are utilized or not utilized. Corresponding demographic and epidemiologic information about population sub— groups is needed, along with the implications of such data for the upcoming aged, so that service needs can be anticipated and planned for. Such information on an ongoing, systematic basis is essential for informed policy decisions and for underpinning much important research. Suggested Areas of Research In a summary report it is not possible to cover all the specific areas of human services delivery that need research. Priority areas of current and potential research include the following. 23 Delivery Process I) What types of facilities, programs, and services are needed for the care of frail elderly in the community? 2) When is it desirable to integrate services? That is, what are viable mixes of general health, mental health, preventive, and rehabilitative, social, and legal services? What impact does integration of services have on patients? How does integration affect cost and efficiency? 3) What are the means for ensuring high quality of care and improved standard— setting procedures? How do we define and measure quality and outcome of care? How do we determine cost-effectiveness of alternative means of service delivery? How do we determine the relationship between type and quality of care and the impact on the people being served? 4) What are the appropriate roles of the various formal service sectors and of other social institutions such as kin, ethnic, and neighborhood groups and voluntary groups and agencies? How do these best interrelate to serve effectively? Utilization of Services 5) To what extent do people use services? How has the extent of use been chang— ing? What is the extent of use likely to be in the near future, given the current trends? 6) How would national health insurance coverage for health care and related services affect utilization? How are services to be financed? What types and numbers of manpower and facility resources will be needed? 7) What is the impact of attitudes of professionals and other service providers on services to the elderly and on the utilization of the services? What are the cultural, social, and ethnic barriers to access to and effective use of available services? 8) What are the means for ensuring equity of access to services and equity of services for all those needing them? 9) How and in what way do physical environmental factors benefit or hinder individuals in maintaining their maximum level of functioning? Research Methods l0) What techniques and methodologies should be developed for evaluating the efficiency, effectiveness, and social benefits of services? To overcome gaps in knowledge, we need reliable data, more accurate ways of measuring needs for an effectiveness of services, and ways of financing services. To successfully deliver services, imaginative solutions and social experiments must be ap— plied to problems related to the institutions and individuals that provide and receive servuces. 24 fi U, S. GOVERNMENT PRINTING OFFICE: 1978 722 643/922 DHEW Publication No. 78-1446 (029195105