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lOtoCoHa™. | SENATE { ^Zul'f 

1st Session 1 I Volume z 



DEVELOPMENTS IN AGING: 1992 
VOLUME 2— APPENDIXES 



A REPORT 



OF THE 



SPECIAL COMMITTEE ON AGING 
UNITED STATES SENATE 



PURSUANT TO 



S. RES. 71, SEC. 19(b), FEBRUARY 25, 1992 

Resolution Authorizing a Study of the Problems of the 
Aged and Aging 



April 20 (legislative day, April 19), 1993.— Ordered 
to be printed 



1 1 ' \m-(<&) 



lOtoCoNau. ] SENATE ( 
is* Session J I Volume ^ 


JJIl DEVELOPMENTS IN AGING: 1992 
o VOLUME 2— APPENDIXES 




A REPORT 




OF THE 




SPECIAL COMMITTEE ON AGING 
UNITED STATES SENATE 




PURSUANT TO 




S. RES. 71, SEC. 19(b), FEBRUARY 25, 1992 


Resolution Authorizing a Study of the Problems of the 
Aged and Aging 


CMS Library ^^Ww 
I C2-Q7-13 
1 7500 Security Blvd. 
| Baltimore, Maryland 21244 




April 20 (legislative day, April 19), 1993 —Ordered 
to be printed 




U.S. GOVERNMENT PRINTING OFFICE 
65-505 WASHINGTON : 1993 





SPECIAL COMMITTEE ON AGING 



DAVID PRYOR, Arkansas, Chairman 



JOHN GLENN, Ohio 

BILL BRADLEY, New Jersey 

J. BENNETT JOHNSTON, Louisiana 

JOHN B. BREAUX, Louisiana 

RICHARD SHELBY, Alabama 

HARRY REID, Nevada 

BOB GRAHAM, Florida 

HERB KOHL, Wisconsin 

RUSSELL D. FEINGOLD, Wisconsin 

ROBERT KRUEGER, Texas 



WILLIAM S. COHEN, Maine 
LARRY PRESSLER, South Dakota 
CHARLES E. GRASSLEY, Iowa 
ALAN K. SIMPSON, Wyoming 
JAMES M. JEFFORDS, Vermont 
JOHN McCAIN, Arizona 
DAVE DURENBERGER, Minnesota 
LARRY CRAIG, Idaho 
CONRAD BURNS, Montana 
ARLEN SPECTER, Pennsylvania 



Portia Porter Mittelman, Staff Director 
Mary Berry Gerwin, Minority Staff Director/Chief Counsel 



(II) 



LETTER OF TRANSMITTAL 



U.S. Senate, 
Special Committee on Aging, 
Washington, DC, March 8, 1993. 

Hon. Albert A. Gore, Jr., 
President, U.S. Senate, 
Washington, DC. 

Dear Mr. President: Under authority of Senate Resolution 71, 
agreed to February 25, 1992, I am submitting to you the annual 
report of the U.S. Senate Special Committee on Aging, Develop- 
ments in Aging: 1992, volume 2. 

Senate Resolution 4, the Committee Systems Reorganization 
Amendments of 1977, authorizes the Special Committee on Aging 
"to conduct a continuing study of any and all matters pertaining to 
problems and opportunities of older people, including but not limit- 
ed to, problems and opportunities of maintaining health, of assur- 
ing adequate income, of finding employment, of engaging in pro- 
ductive and rewarding activity, of securing proper housing and, 
when necessary, of obtaining care and assistance." Senate Resolu- 
tion 4 also requires that the results of these studies and recommen- 
dations be reported to the Senate annually. 

This report describes actions taken during 1992 by the Congress, 
the administration, and the U.S. Senate Special Committee on 
Aging, which are significant to our Nation's older citizens. It also 
summarizes and analyzes the Federal policies and programs that 
are of the most continuing importance for older persons and their 
families. 

On behalf of the members of the committee and its staff, I am 
pleased to transmit this report to you. 
Sincerely, 

David Pryor, Chairman. 



(in) 



CONTENTS 



Page 



Letter of transmittal hi 

Appendix 1. Annual Report of the Federal Council on Aging 1 

Appendix 2. Report from Federal Departments and Agencies 9 

Item 1. Department of Agriculture: 

Agricultural Research Service 9 

Economic Research Service 17 

Cooperative Extension System 18 

Farmers Home Administration 26 

Food and Nutrition Service 26 

Food Safety and Inspection Service 28 

Forest Service 28 

Item 2. Department of Commerce 29 

Item 3. Department of Defense 35 

Item 4. Department of Education 37 

Item 5. Department of Energy 37 

Item 6. Department of Health and Human Services 42 

Health Care Financing Administration 42 

Administration for Children and Families 78 

Administration on Aging 83 

Social Security Administration 129 

Office of Inspector General 134 

Office of Planning and Evaluation 135 

Office of the Surgeon General 140 

Public Health Service: 

Centers for Disease Control 140 

Food and Drug Administration 151 

Health Resources and Services Administration 162 

National Institutes of Health 171 

National Institute of Mental Health 249 

Item 7. Department of Housing and Urban Development 272 

Item 8. Department of the Interior 282 

Item 9. Department of Justice 293 

Item 10. Department of Labor 296 

Item 11. Department of State 302 

Item 12. Department of Transportation 302 

Item 13. Department of the Treasury 309 

Item 14. ACTION 315 

Item 15. Commission on Civil Rights 321 

Item 16. Consumer Product Safety Commission 322 

Item 17. Environmental Protection Agency 322 

Item 18. Equal Employment Opportunity Commission 322 

Item 19. Federal Communications Commission 341 

Item 20. Federal Trade Commission 341 

Item 21. General Accounting Office 356 

Item 22. Legal Services Corporation 393 

Item 23. National Endowment for the Arts 396 

Item 24. National Endowment for the Humanities 402 

Item 25. National Science Foundation 407 

Item 26. Office of Consumer Affairs 409 

Item 27. Pension Benefit Guaranty Corporation 414 

Item 28. Postal Service 414 

Item 29. Railroad Retirement Board 418 

Item 30. Small Business Administration 422 

Item 31. Veterans' Affairs 425 

(v) 



103d Congress 
1st Session 



[COMMITTEE PRINT] 

SENATE 



Rept. 103-40 
Volume 2 



DEVELOPMENTS IN AGING: 1992 
VOLUME 2— APPENDIXES 



April 20 (legislative day, April 19), 1993.— Ordered to be printed 



Mr. Pryor, from the Special Committee on Aging, 
submitted the following 

REPORT 



APPENDIXES 



Appendix 1 

ANNUAL REPORT OF THE FEDERAL COUNCIL ON THE 

AGING 



December 18, 1992. 

Dear Mr. Chairman: On behalf of the Federal Council on the Aging, I am pleased 
to submit a preliminary summary of the 1992 annual report. 

This document examines the history and present membership of the Council. It 
also highlights the various positions taken by the Council on a number of legislative 
and other issues concerning the well-being of the elderly. We are hopeful that the 
Council's views will be considered as the One Hundred and Third Congress con- 
venes. 

We appreciate the continuing interest of the Special Committee on Aging and 
look forward to another year of cooperative efforts with committee members and 
staff toward our mutual goal of service to older Americans. 
Sincerely, 

Max L. Friedersdorf, Chairman. 



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2 



SUMMARY OF THE 1992 ANNUAL REPORT 
L Introduction 

A. BACKGROUND 

The Federal Council on the Aging (FCoA) is the functional successor to the earlier 
and smaller Advisory Council on Older Americans, which was created by the Older 
Americans Act of 1965. In 1973, when the FCoA was created, Congress was con- 
cerned about Federal responsibility for the interests of older Americans, and the 
breadth of vision that such responsibility would reflect. Having decided to upgrade 
the existing advisory committee, Congress patterned the legislative language au- 
thorizing the FCoA after the charter of the U.S. Commission on Civil Rights. 

The FCoA is authorized by Section 204 of the Older Americans Act, as amended. 
The Council is composed of 15 members appointed five members each by the Presi- 
dent, the House of Representatives, and the Senate. Council members, who are ap- 
pointed for 3-year terms, represent a cross-section of rural and urban older Ameri- 
cans, national organizations with an interest in aging, business and labor, minori- 
ties, Indian tribes, and the general public. According to statute, at least nine mem- 
bers must themselves be older individuals. 

The President selects the Chairperson of the Council from the appointed mem- 
bers. The FCoA is mandated to meet at least quarterly, and at the call of the Chair- 
person. 

Functions of the Council include: 

Continually reviewing and evaluating Federal policies and programs affecting 
the aging for the purpose of appraising their value and their impact on the lives 
of older Americans; 

Serving as spokesperson on behalf of older Americans by making recommen- 
dations about Federal policies regarding the aging and federally conducted or 
assisted programs and other activities relating to or affecting them; 

Informing the public about problems and needs of the aging by collecting and 
disseminating information, conducting or commissioning studies and publishing 
their results, and by issuing reports; and 

Providing public forums to discuss and publicize the problems and needs of 
the aging and obtaining information relating to those needs by holding public 
hearings and by conducting or sponsoring conferences, workshops, and other 
such meetings. 

The Council is required by law to prepare an annual report for the President by 
March 31 of the ensuing year. Copies are distributed to Members of Congress, gov- 
ernmental and private agencies, institutions of higher education and individual citi- 
zens interested in FCoA activities. 

Funds appropriated for the Council are included in the overall appropriation of 
the Department of Health and Human Services (DHHS). These funds are used to 
underwrite meetings of the Council, to support staff, and publish information tracts 
authorized by the Council. 

The results of its public meetings and activities concerning issues and policies af- 
fecting older Americans are shared with the President, Congress, the Secretary of 
DHHS, the Commissioner of the Administration on Aging (AoA), National and State 
Aging organizations, and others interested in the well-being of older Americans. 

B. MEMBERS OF THE FEDERAL COUNCIL ON THE AGING 

June Allyson, Los Angeles, CA. — Appointed to a 3-year term ending in January 1992 
by President Reagan, Ms. Allyson has been an actress working through the 
Jerico Group in Los Angeles since 1944. 

Ingrid C. Azvedo, Elk Grove, CA. — Appointed to a 3-year term ending in January 
1992, Mrs. Azvedo was appointed to her second term as Council Chairman by 
President Reagan in 1989. Mrs. Azvedo has been advocating for senior programs 
with the California legislature and Governor's office for many years. She main- 
tains an active schedule of speaking engagements throughout the State of Cali- 
fornia, discussing senior issues and programs both in the private and public sec- 
tors. She also served on the Governor's Task Force on Long-Term Care and as a 
Commissioner on the California Commission on Aging. Currently, she serves as 
an Associate Justice on the California Unemployment Insurance Appeals Board. 

Bernard M. Barrett, Jr., M.D., Houston, TX. — Appointed by President Bush to a 3- 
year term ending in November 1994, Dr. Barrett is Chairman of the Texas Insti- 
tute of Plastic Surgery and Associate Chief of Plastic and Reconstructive Sur- 
gery and attending surgeon at St. Luke's Episcopal Hospital in Houston. Dr. 



3 



Barrett is also Associate Clinical Professor of Plastic Surgery at Baylor College 
of Medicine, The Texas Medical Center, in Houston. 

Virgil S. Boucher, Peoria, IL. — Appointed to a 3-year term ending in July 1993 by 
Speaker of the House Thomas Foley on the recommendation of House Minority 
Leader Robert Michel, Mr. Boucher is an active advocate for programs dealing 
with crimes against the elderly. 

Eugene S. Callender, New York City, NY. — Appointed by House Speaker Foley to a 
3-year term ending in June 1994, Dr. Callender is a clergyman and an attorney. 
He served as Director of the New York State Office on Aging from 1983 to 1989. 
He is a vice-chairperson of the National Council and Center for the Black Aged 
and is the President of the S.Y.D.A. Foundation. 

Robert L. Goldman, Oklahoma City, OK. — Appointed to a 3-year term ending in Oc- 
tober 1993 by the President Pro-Tempore of the Senate upon the recommenda- 
tion of Minority Leader Robert Dole. Since retirement from the Bell System in 
1979, Mr. Goldman has been an active advocate for improving the quality of life 
for older Americans. He is a member of the boards of numerous senior advocacy 
and service organizations, and maintains an intergenerational interest by work- 
ing with handicapped school children. Currently, Mr. Goldman serves on the 
Oklahoma State Council on Aging, Vice President of the Oklahoma State Board 
of Nursing Homes, and as a member of the Oklahoma State Commission on 
Health Care. 

Connie Hadley, Kansas City, KS. — Appointed by the President Pro-Tempore of the 
Senate upon the recommendation of Minority Leader Robert Dole to serve the 
remainder of the term of Mary Majors, which expires in February 1992. Mrs. 
Majors passed away in April 1991. Mrs. Hadley is an active senior with a long 
involvement in community programs. A respected and influential voice in the 
community, she is especially active in promoting programs to help the low- 
income and minority elderly. She is a former Executive Director of the Econom- 
ic Opportunity Foundation, Inc., in Kansas City, and is a member of Senior Or- 
ganized Citizens of Kansas. She also serves on the board for Foster Grandpar- 
ents in Wyandotte County, and was the first County Senior Citizens Coordina- 
tor. 

Tessa Macaulay, Deerfield Beach, FL. — Appointed by House Speaker Foley to a 
second 3-year term ending in August 1992, Ms. Macaulay is Coordinator of Ge- 
rontological Programs at Florida Power & Light Company. 

Josephine K. Oblinger, Springfield, IL. — Appointed by Speaker of the House Thomas 
Foley on the recommendation of House Minority Leader Robert Michel to a 
second 3-year term ending in March 1992, Mrs. Oblinger has had an extensive 
career as a State Legislator. Currently, she is Director of Senior Involvement in 
the Office of Governor James Edgar. 

Kathleen L. Osborne, Los Angeles, CA. — Appointed by President Reagan to a 3-year 
term ending in January 1992. Ms. Osborne served as executive assistant to and 
office manager for President Reagan until June 1991. She is currently an agent 
with Coldwell Banker Real Estate Co. in Sacramento, California. 

Raymond Raschko, Spokane, WA. — Mr. Raschko was appointed on August 11, 1989, 
by House Speaker Foley to serve the remainder of a 3-year term ending in July 
1990, and was appointed to serve a full 3-year term ending in July 1993. Mr. 
Raschko serves as Director of Elderly Services with the Spokane Community 
Mental Health agency, and as a member of the Washington State Long-Term 
Care Commission. He also serves as Director of the Greater Spokane Chapter of 
the Alzheimer's Association. 

Patricia A. Riley, Brunswick, ME. — Appointed by the President Pro-Tempore of the 
Senate upon the recommendation of Senate Majority Leader George Mitchell to 
a 3-year term ending in May 1992. Ms. Riley is President of the nonprofit 
Center for Health Policy Development and executive director of its affiliate, the 
National Academy for State Health Policy. She previously served as Director of 
the Bureau of Maine's Elderly and its Bureau of Medical Services. She has 
served as a member of the American Bar Association's Commission on Legal 
Problems of the Elderly, and is currently on the Kaiser Commission on Medic- 
aid Reform. 

Norman E. Wymbs, Boca Raton, FL. — Appointed to a 3-year term ending in January 
1992 by President Reagan. Mr. Wymbs is a former Mayor of the City of Boca 
Raton. He has been Chairman of a District Mental Health Board and of the 
Boca Raton Housing Authority. An elected official of the Florida Republican 
Party for 14 years, Mr. Wymbs is the author of "A Place to Go Back To", a 
biography of Ronald Reagan's boyhood, and "Sold to the Highest Bidder", a 



4 



treatise on Washington political financing. He currently serves as Chairman of 
the nonprofit Ronald Reagan Home Foundation, Inc. 

E. Don Yoak, Spencer, WV. — A native of West Virginia, Mr. Yoak was appointed by 
the President Pro-Tempore of the Senate upon the recommendation of Senate 
Majority Leader Robert C. Byrd to a 3-year term ending in July 1992, and reap- 
pointed by House Speaker Foley to a 3-year term ending in October 1995. He is 
retired from the West Virginia Department of Highways and has been active in 
West Virginia Legislatures for the last 50 years. Mr. Yoak currently serves as 
Doorkeeper of the West Virginia House of Delegates, on the Board of Directors 
of the West Virginia State College Metro Area Agency on Aging, and as State 
Coordinator for the AARP Citizen Representation Program, which is designed 
to coordinate governmental agencies with seniors to serve on councils, commis- 
sions, boards, and advisory panels. 

Virginia Zachert, Augusta, GA. — Appointed to a 3-year term ending in March 1993 
by the President Pro-Tempore of the Senate upon the recommendation of 
Senate Majority Leader George Mitchell. Dr. Zachert holds a Ph.D. in industrial 
psychology. She currently serves with the Georgia Silver Haired Legislature as 
President of the Senate and Chairman of the Board of Directors, and is a 
member of the Georgia Council on Aging. Dr. Zachert has published numerous 
articles in the fields of medical teaching and aging. She is a former Federal em- 
ployee and Professor Emerita of the Department of OB-GYN of the Medical 
College of Georgia. 
During 1992 four members were newly appointed to the Council: 

Max L. Friedersdorf, Sanibel, FL. — Chairman — Appointed by President Bush to a 3- 
year term ending in June 1995. Mr. Friedersdorf has been designated by the 
President as Chairman of the Council. His nearly 28 years of experience in high 
level positions in the Federal Government include 8 years in the White House 
as Assistant to the President for Congressional Liaison under Presidents Nixon, 
Ford and Reagan. He is Senior Vice President with Neill and Company in 
Washington, D.C., and serves as Chairman of the Advisory Board for the Asso- 
ciation of Retired Americans. A native of Indiana, he attended Franklin Col- 
lege, where he was awarded a B.A. in Journalism and an Honorary Doctorate of 
Laws. He has also earned an M.A. in Communications from American Universi- 
ty in Washington, D.C. 

Rudolph Cleghorn, El Reno, OK. — Appointed by the President Pro-Tempore of the 
Senate upon the recommendation of Senate Majority Leader George Mitchell to 
a 3-year term ending in October 1995. Following his retirement as a case man- 
ager with the U.S. Department of Justice, Mr. Cleghorn served for 10 years as 
program manager of a Title VI program, and was instrumental in the forma- 
tion of the National Association of Title VI Directors. He was a staff member of 
Three Feathers Associates which administered a grant to train Title VI direc- 
tors. In 1984, he was appointed to AARP's ad-hoc Committee on Minority Af- 
fairs, and in 1988 to the Minority Concerns Committee of the National Council 
on the Aging. He is a member of numerous aging and Indian organizations, and 
is a member of the Otoe-Missouri and Cherokee-Delaware Indian Tribes. 

Stephen Farnham, Presque Isle, ME. — Appointed by the President Pro-Tempore of 
the Senate upon the recommendation of Senate Majority Leader George Mitch- 
ell to a 3-year term ending in October 1995. Mr. Farnham is the executive direc- 
tor of the Aroostook Area Agency on Aging, Inc., serves as President of the 
Aroostook Regional Transportation System, Inc., and voluntarily directs the op- 
eration of the Caribou Congregate Housing Development Corporation. He is a 
strong advocate for the needs of vulnerable older people in Maine and has 
served 3 years as a board member with the National Association of Area Agen- 
cies on Aging (NAAAA). 

Charles W. Kane, Stuart, FL. — Appointed by President Bush to serve a 3-year term 
ending in June 1995. Mr. Kane is retired from an extensive Federal Govern- 
ment career in security and law enforcement. A native of Illinois, Mr. Kane re- 
ceived a B.A. degree from the University of Illinois, and a Juris Doctor Degree 
from American University. He has been active in local councils on aging and 
served as a member of Florida's Pepper Commission. He currently serves as a 
member of the Advisory Council of the Florida Department of Elder Affairs. 

C. CALENDAR 1992 MEETING DATES 

The Council met four times during 1992, as required by the Older Americans Act. 
The meeting dates were February 27-28, May 13-14, September 23-24, and Decem- 
ber 7-8. The meetings were held in Washington, D.C. 



5 



All FCoA meetings were announced in the Federal Register and notices of the 
meetings sent to representatives of national organizations, staff of various Federal 
agencies, and to Congressional members and committees interested in or responsible 
for aging. Minutes are distributed to individuals who attended the meetings and to 
any interested parties who request them. Publications and documents pertinent to 
official actions are maintained in the Office of the Federal Council on the Aging and 
are available to the general public. The FCoA mailing address is: Room 4280, 
Wilbur J. Cohen Federal Building, 330 Independence Avenue, S.W., Washington, 
D.C. 20201-0001. 

D. COUNCIL MEETINGS SCHEDULED FOR CALENDAR 1993 

Current plans call for the Council to meet in 1993 as follows: February 23-24, 
May 13-14, September 23-24, and December 7-8. 

II. Action of the Federal Council on the Aging During Calendar Year 1992 

A. REAUTHORIZATION OF THE OLDER AMERICANS ACT 

The Council closely monitored developments in the debate over the Reauthoriza- 
tion of the Older Americans Act of 1965 and the related discussion of the proposed 
revisions of the Social Security Earnings Test. Regular briefings were provided by 
the Commissioner on Aging summarizing the implications of the legislation and the 
delay of its passage on programs under the Act, including the White House Confer- 
ence on Aging. 

B. MENTAL HEALTH AND THE ELDERLY 

To continue with their focus on mental health issues confronting the elderly 
which began with their November 1990 symposium on the issues, the Council con- 
tinued development of a comprehensive study of Mental Health and the Elderly, 
with the assistance of the National Institute on Mental Health (NIMH). The Coun- 
cil's 1980 publication, Mental Health and the Elderly: Recommendations for Action, 
serves as a starting point for the new study. The study, which is intended to in- 
crease awareness of the mental health needs of the elderly throughout both the 
mental health and aging networks, is slated for completion in 1993. 

Also, the Council recommended revisions in the text of H. Con. Res. 296, which 
called for mental health treatment to be included in any health care reform propos- 
als considered by Congress. The resolution as proposed failed to highlight the impor- 
tance of mental health to the well being of older persons. The Council recommended 
additional language, and endorsed the resolution as amended. 

C. OLDER PERSONS LIVING ALONE 

Issues of particular concern to older persons who live alone were examined by the 
Council throughout 1992. Briefings included a presentation by the staff of the 
Center on Elderly People Living Alone during the February meeting. The Council 
has determined that better information is needed to describe and define this cohort 
of the older population. 

D. OUTREACH AND BARRIERS TO ACCESS TO SERVICES 

The Council focused effort on the identification and elimination of obstacles en- 
countered by older persons in need of existing services, and programs available to 
assist in accessing them. Provisions of the Americans with Disabilities Act (ADA) 
were closely examined, including briefings provided by the National Council on Dis- 
ability and the National Eldercare Institute on Transportation. Barriers encoun- 
tered by Indian Elders and older persons who live alone were also explored. 

E. OLDER PERSONS AND THE MEDIA 

The Council continued to compile and analyze information related to the portray- 
al of older persons in the entertainment, news media, and advertising industries. Of 
particular interest was a survey conducted by the University of California at Los 
Angeles (UCLA) under a grant from the Administration on Aging. 

F. ISSUES FACING INDIAN ELDERS 

Throughout 1992, the Council has closely examined issues of concern to older Indi- 
ans. An Indian Task Force has been established to serve as a liaison for the Council 
with the Indian Health Service, the National Indian Council on Aging (NICOA), the 



6 



Associate Commissioner for Title VI at the Administration on Aging, and other gov- 
ernment, congressional, and nonprofit entities involved with older Indians. Briefings 
were provided by officials of NICOA, the Indian Health Service, and by the Associ- 
ate Commissioner. The Executive Director participated in the White House Confer- 
ence on Indian Aging in September. Also, Council members participated in Congres- 
sional hearings and briefings focusing on Indian Elders. 

G. THE NATIONAL ELDERCARE CAMPAIGN 

The Federal Council on the Aging has taken an active role in the National Elder- 
care Campaign, being conducted by the U.S. Administration on Aging. The Council 
has met regularly with the organizers of the initiative, closely monitored its 
progress, and advised the Commissioner on Aging on key issues in the Campaign 
strategy. Members of the Council were participants in several forums and planning 
sessions regarding the Campaign, and received regular briefings from the U.S. Com- 
missioner on Aging on its progress. 

H. THE LOS ANGELES RIOTS AND HURRICANE ANDREW 

Council Members closely monitored efforts to assist older persons directly affected 
by these crises. Members gave first hand reports following onsite visits, and the 
Council was regularly briefed by the U.S. Commissioner on Aging regarding Federal 
efforts to assist the elderly. 

I. FETAL TISSUE RESEARCH 

The Council closely monitored the ongoing debate over government support of the 
use of fetal tissue in research at the National Institutes of Health. A temporary 
committee was established to gather information and to inform the Council Mem- 
bers on the issue. After considerable discussion, the Council voted to postpone 
formal action on fetal tissue research. 

J. MEMBERSHIP ACTIVITIES 

In anticipation of the 20th Anniversary of the creation of the Federal Council on 
the Aging in 1993, the Council has been active in locating and communicating with 
former members of the Council. Also, the Council has worked to strengthen the ori- 
entation procedures for newly appointed members. 

K. WHITE HOUSE CONFERENCE ON THE AGING 

Throughout 1992, the Council closely monitored legislative and other develop- 
ments regarding the White House Conference on the Aging. Council Members an- 
ticipate playing a leadership role in planning for the Conference. 

L. AGING AMERICA: TRENDS AND PROJECTIONS 

The FCoA participated for the third time in the development, printing, and distri- 
bution of the demographic report — Aging America: Trends and Projections, 1991 
Edition. The publication is a cooperative effort with the Administration on Aging, 
the Senate Special Committee on Aging and the American Association of Retired 
Persons (AARP). 

M. LEGISLATIVE BRIEFINGS AND ACTIVITIES 

The Council has closely monitored congressional hearings and briefings on issues 
affecting the elderly, as well as resulting legislative activity. During their February 
Meeting, the Council participated in a training session conducted by Congressional 
Quarterly, Inc., entitled "Understanding Congress." 

III. Future Developments 

A. PREPARATIONS FOR THE WHITE HOUSE CONFERENCE ON AGING 

The Council will continue to closely monitor legislative and other developments 
regarding the White House Conference on Aging, now mandated by the Older 
Americans Act. The Federal Council on the Aging will continue to play a major 
leadership role in planning for the Conference, and call for swift Administration 
action on the requirements of the Act. 



7 



B. MENTAL HEALTH AND THE ELDERLY 

The Council will continue work on the publication of a report on Mental Health 
Issues affecting the Elderly, which seeks to identify and encourage ways to improve 
coordination between the Aging and Mental Health Networks in improving access 
for the elderly to services provided by both networks. 

C. HEALTH CARE REFORM 

The Council will review and evaluate proposals put forth to reform the Nation's 
health care delivery system, assess the potential impact on the elderly, and issue 
recommendations to the President, the Congress, and others as appropriate. 

D. LONG-TERM CARE 

The Council will continue to closely monitor progress in addressing the growing 
long-term care needs of the Nation's ever-increasing older population, and advocate 
for provisions which will support the efforts of older individuals to remain in their 
homes leading lives of independence and dignity for as long as possible. 

E. OLDER PERSONS LIVING ALONE 

The Council will continue to investigate the unique issues and challenges facing 
older persons who live alone in their communities, with special emphasis on mental 
health issues which may arise in such situations. 

F. BARRIERS TO ACCESS 

The Council will identify and investigate various barriers which inhibit the access 
of older persons to supportive programs and services for which they may qualify, 
with particular emphasis on special populations including minorities, persons with 
low income, and persons with mental health problems. Included will be a review of 
various programs in place to eliminate such barriers. 

G. OLDER PERSONS IN THE MEDIA 

The Council will assess the nature and impact of the portrayal of older persons in 
the entertainment industry and other media, and the degree to which negative 
stereotypes of the elderly are perpetuated. 

H. NATIVE AMERICAN ELDERS 

The Council will continue to review the status of issues facing Native American 
Elders, and to advocate for improvements in the quality of life for older Indians. 



APPENDIX 2 



Report From Federal Departments and Agencies 

ITEM 1. DEPARTMENT OF AGRICULTURE 

January 7, 1993. 

Dear Mr. Chairman: Enclosed is the information you requested on the Depart- 
ment's activities or initiatives on behalf of older Americans and their families. If we 
can be of any further assistance, please feel free to call. 
Sincerely, 

Edward Madigan, 

Secretory- 
Enclosure. 

AGRICULTURAL RESEARCH SERVICE— RESEARCH RELATED TO THE 

ELDERLY 

Studies are conducted at the USDA Human Nutrition Research Center on Aging 
(HNRCA) at Tufts University, Boston, Massachusetts, which address the following 
problems of the aging: 

1. What are nutrient requirements to insure optimal function and well being 
for a maturing population. 

2. How does nutrition influence the progressive loss of tissue function associ- 
ated with aging? 

3. What is the role of nutrition in the genesis of major chronic, degenerative 
conditions associated with the aging process? 

In addition, studies are performed at the Beltsville Human Nutrition Research 
Center (BHNRC), the Grand Forks Human Nutrition Research Center (GFHNRC), 
and the Western Human Nutrition Research Center (WHNRC) on the role of nutri- 
tion in the maintenance of health and prevention of age-related conditions, includ- 
ing cancer, coronary heart disease, hypertension, diabetes, neurological disorders, 
osteoporosis, and immunocompetence. Summaries of agricultural research progress 
and a list of projects related to nutrition and the elderly are attached. 

Highlights of Research Findings Related to Nutrition And Prevention of 
Disorders Associated With Aging 

vitamin c intake and blood pressure in the elderly 

Elevated blood pressure (BP) is a powerful determinant of cerebrovascular and 
coronary heart disease. The importance of nutrition in the control of blood pressure 
is well documented, with obesity, dietary sodium, and alcohol being associated with 
higher BP, and increased intakes of potassium and calcium associated with lower 
BP. Since inverse associations between BP and vitamin C have also been reported, 
scientists at the Human Nutrition Research Center on Aging at Tufts University in 
Boston, MA, undertook an analysis of data from a large cross-sectional study of 
health and nutrition in a group of noninstitutionalized elderly subjects. They found 
half as many cases of elevated BP in subjects consuming 240 milligrams or more per 
day of vitamin C than they did in those consuming less than 60 milligrams per day. 
This finding lends support to the hypothesis that diets low in vitamin C are related 
to increased BP. However, further research is required to test whether the vitamin 
C itself — or some other component of a low vitamin C diet — is responsible for the 
elevated BP. 



(9) 



10 



EFFECTS OF EXERCISE AND VITAMIN E ON HOST DEFENCE RESPONSES 

Interleukin-1 (IL-1), tumor necrosis factor (TNF), and interleukin-6 (IL-6) are pro- 
teins that induce host defence responses to trauma and disease. Scientists at the 
ARS Human Nutrition Research Center on Aging, have been studying the produc- 
tion of these proteins and their plasma levels in subjects subjected to downhill run- 
ning on a treadmill, and supplemented with vitamin E. 

The day after exercise, IL-1 production increased in cells from subjects taking a 
placebo, but did not increase in cells from subjects taking vitamin E capsules. TNF 
production also increased the day after exercise, although the response was not 
blocked by vitamin E. IL-6 production was unchanged after exercise, but vitamin E 
reduced the secretion of IL-6 at all times. Thus, immune factors seem to be related 
to changes in muscle protein, and vitamin E which can affect these immune factors. 

WHAT ARE THE DIETARY ENERGY NEEDS OF ADULTS? 

Accurate recommendations on dietary energy (calorie) requirements form the 
basis for determining the amounts of food aid given to poor families, and also for 
assessing whether the food supply of different communities is adequate. Current 
Recommended Dietary Allowances (RDA) on energy needs are based on theoretical 
calculations because it was not previously possible to measure actual energy needs 
directly in individuals leading normal lives. 

Now, scientists at the ARS Human Nutrition Center on Aging have successfully 
used the doubly-labeled water technique to make direct measurement of the energy 
requirements of young and old men. Findings indicate that energy recommendations 
have substantially underestimated usual energy needs and suggest that current 
RDA's may significantly underestimate usual energy requirements for physical ac- 
tivity. These new data contribute to a growing realization of the need to reevaluate 
energy intake recommendations and analysis of food consumption data. 

EFFECTS OF UNDERFEEDING ON ENERGY EXPENDITURE AND SUBSEQUENT NUTRIENT 

INTAKES 

The mechanisms of body weight regulation are not well understood. Scientists at 
the ARS Human Nutrition Research Center on Aging, recently observed the effects 
of intentional underfeeding — by 800 kilocalories each day, for 20 days — upon 
normal-weight young men with high levels of energy expenditures and leading unre- 
stricted lives. Researchers found that energy expenditure did not fall significantly 
with reduced energy intake. They also found the subjects' voluntary energy intake 
following the dietary restriction to increase initially above the basic amount re- 
quired for body weight maintenance, to be proportional to the weight loss during 
underfeeding, and to rapidly restore the weight lost during underfeeding. Results 
indicate that (1) appetite — rather than adaptive variations in energy expenditure — 
plays the dominant role in day-to-day regulation of body weight, (2) energy balance 
is regulated primarily by adaptive variations in energy (food) intake, and (3) the hy- 
pothesis that energy-wasting mechanisms contribute substantially to body energy 
regulation is not confirmed. 

HIGH DIETARY FRUCTOSE AFFECTS PLASMA CHOLESTEROL CONCENTRATIONS AND SIGNS OF 
SHORT-TERM COPPER DEPRIVATION IN MEN 

Animal experiments, epidemiologic studies, and findings with humans suggest 
that copper is more important in nutrition than currently recognized. One reason 
that copper has not been well-accepted as a nutritional concern is that attempts to 
produce signs of copper deprivation in adult humans have not yielded consistent 
findings. Thus, a study was performed at the ARS Grand Forks Human Nutrition 
Research Center to see if cornstarch and fructose affected the response of men to 
short-term copper deprivation. Fructose can enhance the formation of active mole- 
cules known as free radicals which cause damage to tissues. Copper is part of the 
defense mechanism against this damage known as oxidant damage. When compared 
to cornstarch, fructose increased serum cholesterol (this increase was mostly in the 
"bad" or LDL-cholesterol fraction) altered the copper deprivation signs associated 
with oxidative metabolism. This suggests that high consumption of dietary sub- 
stances that increase the formation of free radicals could make copper nutriture of 
concern. 



11 



CONTINUING BONE EXPANSION AND INCREASING BONE LOSS OVER A TWO-DECADE PERIOD 
IN MEN AND WOMEN FROM A TOTAL COMMUNITY SAMPLE 

Bone measurements and dietary data were obtained for an anthropometric study 
at the Human Nutrition Research Center on Aging in a sample of 744 men and 
women from one community. Bone lose was found to begin by the fifth decade and 
increased thereafter. The smaller gain at the outer bone surfaces are independent of 
the larger loss at the endosteal (inner) bone surface. Although net bone loss was 
nearly as great in men as in women, bone loss over two decades constituted a larger 
percentage of the initially smaller bone mass in females. Trends in two-decade bone 
changes were not affected by smoking behavior, alcohol, antihypertensive medica- 
tion or early menopause. Long-term bone change were independent of energy and 
mineral intake. Though dietary intake does not predict long-term bone changes, the 
amount of initial bone tissue was highly correlated with tissue bone 21.4 years later 
in life for both sexes. 

IMMUNOLOGICAL EFFECTS OF NATIONAL CHOLESTEROL EDUCATION PANEL (NCEP) STEP-2 
DIET WITH AND WITHOUT FISH-DERIVED N-3 FATTY ACID ENRICHMENT 

Reduction in dietary fat, saturated fat and cholesterol (chol) has been recommend- 
ed by public health organizations to reduce the risk of heart disease. However, very 
few studies have looked at the effects of those changes in the diet with regards to 
the modifications of human cytokine production and immune responsiveness. 
Twenty-two volunteers (11 female, 11 male) over the age of 40 participated at the 
ARS Human Nutrition Research Center on Aging, in a thirty week study which was 
divided into two phases. During the first phase (6 wks), the volunteers ate diets 
based on average American diets. During the second phase (24 wks) volunteers ate 
either a lowfat and low cholesterol diet which followed the NCEP recommendations 
(NCEP Step 2) with polyunsaturated fatty acids (PUFA) derived from fish or a diet 
following NCEP Step 2 recommendations — low in fish-derived PUFA but high in 
plant-derived PUFA. The results show that the fish diet have significant effects on 
inflammatory and immune responses. These changes can adversely affect host de- 
fenses and impact on the antiatherogenic effects of these diets. Thus changes in 
immune response should be taken into consideration when such diets are recom- 
mended for the prevention of chronic diseases. 

INTERACTION OF DIETARY PHYTATE AND CALCIUM ON UTILIZATION OF CALCIUM, ZINC, 

AND MAGNESIUM 

Phytic acid is an organic phosphorus compound present in cereals and legumes. 
Both animal and human studies have shown that amounts of phytic acid greater 
than the amount consumed by most U.S. citizens will impair utilization of these ele- 
ments, particularly zinc, when each was studied alone. Interactions between phytate 
and several elements are often much more difficult to ascertain. Scientists at the 
ARS Beltsville Human Nutrition Research Center investigated the effect of dietary 
calcium level on the impairment of zinc utilization by phytate. Eight men consumed 
foods usually consumed by omnivorous Americans, each meal having two bran muf- 
fins each of which contained 5g of wheat bran to provide a phytic acid intake slight- 
ly greater than consumed by most vegetarians in the U.S. Three calcium intakes 
were studied, each for 21 days, equivalent to about 70 percent, 130 percent and 200 
percent of the RDA (recommended daily allowance). The RDA for adult men is 800 
mg daily. Metabolic parameters such as increased fecal excretion and lower urinary 
excretion indicated that dietary calcium utilization was impaired when the low cal- 
cium diet was eaten. However, these indices indicated zinc utilization was lower 
when the high calcium diet was consumed. In vitro (test tube) solubility measure- 
ments indicated that solubility differences were greater than the observed physio- 
logical differences. 

APPARENT MINERAL BALANCE AFTER A HIGH-FAT/LOW-FIBER DIET AND A LOW-FAT/HIGH- 

FIBER DIET 

Recommendations have been made for the U.S. population to decrease fat and in- 
crease fiber intake as a means of reducing their risk of coronary heart disease and 
bowel cancer. Beneficial effects from increasing fiber consumption include decreased 
transit time, reduced symptoms of diverticular disease and with some fibers lowered 
cholesterol levels of glycemic response. 

However, high intakes of some dietary fibers have been implicated with reducing 
apparent mineral retention. Forty-two men consumed a 20 percent fat/54 g fiber/ 
2800 kcal diet (HFibD) and a 40 percent fat/29 g fiber/2800 kcal diet (LFibD) for two 



12 

10 week periods to investigate the effects of consuming a high fiber diet on apparent 
mineral balance. Fiber was added to the diet as legumes, cereals, fruits and vegeta- 
bles rather than a single added source. No significant difference due to the diet was 
observed in mineral parameters tested in the blood. Calcium, iron, zinc, copper, 
magnesium and manganese intake and fecal excretion were significantly higher on 
the HFibD compared to the LFibD. Calcium, zinc, copper, and magnesium showed 
significant positive apparent retention while manganese and iron were not signifi- 
cantly different from zero balance when the HFibD was consumed. The data indicat- 
ed that a high fiber diet containing mineral levels at or above the recommended 
dietary allowance can be consumed for its potential beneficial effects without miner- 
al loss. 

PLASMA HIGH DENSITY LIPOPROTEIN CHOLESTEROL AND APOLIPOPROTEIN AI LEVELS IN 
THE FRAMINGHAM OFFSPRING STUDY! ASSOCIATIONS WITH AGE, GENDER, LIPID LEVELS, 
AND LIFESTYLE FACTORS 

Cholesterol is carried in the bloodstream by different particles. High density lipo- 
protein (HDL) particles carry the so called "good cholesterol", and also contain a 
protein, called apolipoprotein A-I (apo A-I). It has been shown that subjects with 
low levels of HDL cholesterol and apo A-I in their plasma have an increased risk of 
heart disease. Scientists at the Human Nutrition Research Center on Aging have 
measured plasma levels of HDL cholesterol and apo A-I in 1,344 men and 1,337 
women participating in the Framingham Offspring Study. They found that women 
have higher plasma levels of both HDL cholesterol and apo A-I. In addition, sub- 
jects with very low levels of HDL cholesterol and apo A-I had a markedly higher 
body weight and significantly higher plasma triglycerides than subjects with very 
high levels of HDL cholesterol and apo A-I. Furthermore, plasma levels of HDL 
cholesterol and apo A-I were higher in those subjects who were having one or more 
alcohol-containing drinks per week (beer, wine, or liquor) than in those who ab- 
stained from alcohol consumption. Our results indicate that subjects that are lean 
and that have a mild consumption of alcohol have higher levels of "good cholester- 
ol." 

EFFECTS OF AGE, GENDER, AND MENOPAUSE STATUS ON PLASMA LIPOPROTEIN (A) LEVELS: 
THE FRAMINGHAM OFFSPRING STUDY 

Lipoproteins are spherical particles found in the blood. A particular particle, 
known as lipoprotein (a) [Lp(a)] is gaining acceptance as an independent risk factor 
for coronary artery disease. Scientists at the Human Nutrition Research Center on 
Aging measured Lp(a) concentrations in 1284 men and 1394 women in the 3rd cycle 
of the Framingham Offspring Study to establish normal ranges of this lipoprotein 
particles in a population free of heart disease. The average level of this particle in 
both men and women was approximately 15 mg/dl. These levels were found to be 
higher in postmenopausal women than in premenopausal women. Alcohol consump- 
tion and cigarette smoking were not found to be associated with Lp(a) levels. 

REMOTE RECALL OF CHILDHOOD WEIGHT, HEIGHT, AND BODY BUILD BY ELDERLY SUBJECTS 

The long-term recall of weight, height and body build was examined as part of a 
follow-up study by the Human Nutrition Research Center on Aging of an early Har- 
vard growth study. Half of the persons contacted had been overweight in adoles- 
cence and half had been lean. The 181 elderly interviewed subjects were asked to 
recall their high school weight and height and to select outline drawings that best 
reflected their body size at ages 5, 10, 15, and 20. Their reports were compared to 
measurements obtained during school. High school weight was overestimated by ad- 
olescent lean males and underestimated by adolescent obese females. Adolescent 
weight status influenced height recall for females but not for males. Overall, actual 
and recalled high school weight were well correlated for both males and females. 
For height, recalled and measured values were very highly correlated. Correlations 
between recalled body build and weight/height (BMI) measured at approximately 
the same ages were moderate for all ages studied except for males at age 5. The 
association between adolescent BMI and recalled build was only slightly reduced 
when the influence of adult BMI or elderly BMI was accounted for. These results 
indicate that the remote recall of height, weight and body size is reasonably valid 
and demonstrate that recalled body build can contribute useful information inde- 
pendent of current weight status. 



13 



BODY MASS INDEX FROM CHILDHOOD TO MIDDLE-AGE: A 50 YEAR FOLLOW-UP 

Obesity in middle age is associated with various morbidities including cardiovas- 
cular disease, adult-onset diabetes, and some types of cancer. Childhood obesity has 
been implicated as a possible risk factor for obesity in adulthood. Previous studies 
have shown that childhood body size is a good predictor of body size in adolescence 
and early adulthood, but the degree to which weight status in childhood predicts 
that in middle-age has not been established. Studies at the Human Nutrition Re- 
search Center on Aging used historical height and weight data from a longitudinal 
study that has been ongoing for 50 years to investigate the relationship of body size 
in childhood to that of adolescence, young adulthood, and middle-age. As expected, 
childhood body size was a good predictor of body size up to 18 years of age. However, 
there were sex differences when measures in childhood were compared to those in 
middle-age. The stability of body size was better in males — with measures in child- 
hood and adolescence being good predictors of body size and that in middle-age. In 
females, there was no relationship between childhood body size and that in middle- 
age. The lack of association of body size early in life with that in middle-age for 
females was a finding of interest. The sex difference in fatness trends may be ex- 
plained by the dramatic increase in fatness that girls experience during their ado- 
lescence period — which boys do not. Another explanation for the lack of association 
in females is that adult women are far more likely than adult men to consciously 
alter their weight by dieting thus experiencing greater weight fluctuations. 

HEALTH CARE TRENDS 

The future direction of health care in the United States was reviewed by the ARS 
Family Economics Research Group at Hyattsville, Maryland. Out-of-pocket costs to 
individuals and families, as well as costs paid from public funds, were found to con- 
tinue to increase rapidly. Although sophisticated medical computer technology can 
be used to help diagnose, prognosticate, and evaluate treatments, its widespread use 
has added significantly to health care costs. 

Despite the large amount of money allocated to health care, the needs of many 
Americans are not being met: the elderly who need long-term care, AIDS patients 
who have both financial and emotional costs from their disease, the uninsured, and 
the underinsured. Recent developments that can help Americans with their health 
care needs include the establishment of State and community ombudsmen to assist 
families with nursing home problems, the advent of long-term care insurance, and 
the creation of Older Americans Independence Centers. Policymakers and legisla- 
tors, the insurance industry, and health care professionals need to continue their 
efforts to meet the health care needs of the Nation. 

MEETING BASIC NEEDS: FOOD, HOUSING, AND CLOTHING CONCERNS OF RURAL SOUTHERN 

ELDERS 

The ability to meet food, housing, and clothing needs may be influenced by the 
resources elders have available to them. Also, the ability to meet those needs shapes 
elders' level of concern. Data from the regional research project, "Quality of Well- 
Being of the Rural Southern Elderly: Food, Clothing, and Housing," were used by 
the Family Economics Research Group to describe the characteristics of elders who 
said these basic needs were concerns. Results show that higher percentages of study 
participants in all socioeconomic categories said food (61 percent to 43 percent) and 
housing (41 percent to 26 percent) were great concerns than said clothing was a 
great concern (less than 11 percent). Those that had a great concern for food were 
more likely to be married, have less than 8 years of education, live with family or 
others, receive food stamps, and consider food costs a serious issue. Elders that had 
a great concern for housing were more likely to be never marrieds, black, have less 
than 8 years of education, and live alone. They believe their home needs major re- 
pairs, and housing costs are a moderate concern. They spend less than $100 annual- 
ly on home maintenance. Elders that had a great concern for clothing were more 
likely to believe clothing costs, style, a fit were a serious issue; they spend more 
than $200 annually on clothing; and they do not add or update their wardrobe by 
making over old clothing. Findings regarding the concerns of rural Southern elders 
will be useful to family caregivers, community organizations, and social service 
agencies that assist elders. 



14 



Agricultural Research Service — Research projects related to nutrition and the elderly: 

Funding level 

Fiscal year 1992 

Effect of fiber or amylose on metabolic parameters — BHNRC, 05/ 
01/90 to 04/30/95: $200,964 
Objective: To determine the effects of high amylose foods or 
purified versus food fiber on blood parameters associated 
with chronic diseases and mineral bioavailability. 
Relation between nutrition and aging: Cholesterol, bile acid and 
sterol metabolism and fecal mutagenicity — BHNRC, 11/13/89 to 
11/12/93: 546,488 
Objective: To investigate the relationship of fat and other nu- 
trients or components of the human diet to age-related disor- 
ders, such as cancer, and coronary heart disease, as reflected 
by changes in bile acid metabolism, fecal mutagens, hor- 
mones, serum cholesterol, platelet aggregation and other pa- 
rameters affected by diet and suspected of involvement in 
aging disorders. 

Human requirements for selenium and vitamin E — BHNRC, 05/ 
08/87 to 05/07/92: 299,224 
Objective: Investigate selenium metabolism at elevated dietary 
intakes; develop methods for assessing selenium status; de- 
termine feasibility of mathematical models for predicting de- 
sirable dietary selenium intakes; clarify effects of food com- 
ponents on selenium bioavailability; evaluated effect of vari- 
ous stresses on the nutritional need for selenium. To better 
define the physiological role of dietary antioxidant nutrients 
in immune response. 
Newly available carbohydrates in the development of diet for con- 
trol of risk for disease— BHNRC, 02/03/92 to 02/02/97: 644,363 
Objective: To examine use of carbohydrate to maximize physi- 
cal performance in humans. To examine effects of soluble 
fibers on cholesterol metabolism and disease risk in humans 
and animals. To examine long-term effects of carbohydrate 
intake on disease development or prevention. 
Dietary carbohydrates and etiology or prevention of degenerative 
diseases and their complication— BHNRC, 04/01/91 to 03/31/96: 402,808 
Objective: To investigate the underlying mechanisms of how di- 
etary carbohydrates induce biochemical, cellular, molecular 
and structural changes that either increase or decrease the 
risk of degenerative diseases that occur during the aging 
process. 

Nutritional and biochemical role of chromium in health and dis- 
ease— BHNRC, 01/23/90 to 01/22/93: 315,006 
Objective: Determine effects of low Cr intakes of humans on 
variables associated with sugar and fat metabolism. Deter- 
mine the effects of physical performance on trace metal me- 
tabolism. Develop sensitive methods to detect marginal signs 
of chromium deficiency. Determine and define the role of 
chromium in selected abnormalities in glucose metabolism. 
Determine the bioavailability of various forms of chromium. 

Diet and antioxidant status— WHNRC, 10/01/89 to 09/30/94: 638,829 
Objective: Determine the effects of dietary fat and micronu- 
trients on in vivo oxidative damage and antioxidant defense 
status. Determine if tests of oxidative damage or antioxidant 
defense status can be used as functional markers of human 
nutritional status and as sensitive measures for determining 
human requirements for fats and certain micronutrients. 

Dietary fats, nutrition and health— WHNRC, 03/01/90 to 02/28/95: 944,074 
Objective: Evaluate the nutrient composition of the diet with 
emphasis on the quantity and quality of fats in healthy indi- 
viduals and population groups. To study the metabolism of 
dietary fats in relation to health and absence of chronic de- 
generative diseases. 



15 



Fiscal year 1992 

Effects of copper deficiency and its modifiers on cardiovascular me- 
tabolism and function— GFHNRC, 03/04/91 to 03/03/96: 353,316 
Objective: Copper deficiency produces a host of adverse ana- 
tomical, chemical and physiological changes in the cardiovas- 
cular system in several species including man. Chemical fac- 
tors that affect blood coagulation and clot lysis and neuroen- 
docrine mechanisms that affect blood pressure will be stud- 
ied. Modifying factors such as commonly eaten chemicals or 
foods will be studied occasionally. These studies will provide 
information useful in definition of copper requirements. 
Economic status of older Americans— FERG, 01/23/90 to 01/22/93: 144,961 
Objective: Determine income and expenditure patterns of older 
Americans. 

Human mineral element requirements and their modification by 
stressors— GFNRC, 05/13/91 to 05/12/96: 1,319,489 
Objective: Determine the dietary requirements of humans for 
magnesium, copper, and boron, and whether these require- 
ments are affected by nutritional, physiological, hormonal or 
metabolic stressors. Specifically, for humans, to demonstrate 
that copper is of nutritional concern and that its nutritional 
need is enhanced by oxidant stress; to demonstrate that in- 
adequate dietary magnesium can have pathological conse- 
quences; and to confirm that dietary boron affects measures 
of macromineral metabolism, metabolic recycling of vitamin 
K will be identified, isolated, purified and characterized. 

Bioavailability of nutrients in the elderly— HNRCA, 12/11/89 to 

12/10/94: 1,487,272 
Objective: (1) To determine the bioavailability of food folate 
and the impact of aging on this process. (2) To define the 
mechanism of body folate conservation and effect of aging. 
(3) To assess the folate/vitamin B12 status in the elderly 
with respect to cardiovascular and neuropsychiatric func- 
tions. (4) To define the mechanism of age related decreases 
in intestinal absorption of calcium. (5) To study the factors 
that influence the bioavailability of zinc and magnesium. 

Cell programming and regulation during aging regulation by 
iron—HNRCA, 10/01/89 to 09/30/92: 323,804 
Objective: Body stores of iron increase with age and may cause 
tissue damage. To restrict this, excess iron is taken up by 
ferritin. Using recent information about control of ferritin 
synthesis, the effect of aging on efficiency of the ferritin re- 
sponse will be explored and the relationship of this to tissue 
damage by iron will be examined. 

Role of nutritional factors in maintaining bone health in the elder- 
ly— HNRCA, 12/11/89 to 12/10/94: 1,568,055 
Objective: The objective of this lab is to improve the scientific 
basis for understanding and setting the intake requirements 
of calcium and vitamin D in aging adults. Specifically, we 
will define the intake of calcium and vitamin D above which 
skeletal mineral is maximally spared. This requires an un- 
derstanding of how demographic, edocrine, and physical fac- 
tors (e.g. race, sex, age, years since menopause, weight, activ- 
ity level, and the ability to absorb calcium) affect the re- 
quirement of these nutrients. 



16 



Fiscal year 1992 

Relationships between aging, functional capacity, body composition 
and substrate metabolism and need— HNRCA, 12/11/89 to 12/ 
10/94: 1,827,190 
Objective: To examine the effects of increased physical activity, 
body composition and diet on the following: (1) Peripheral in- 
sulin sensitivity and glucose metabolism. (2) Functional ca- 
pacity and nutritional status of the frail, institutionalized el- 
derly. (3) Cytokine production and whole body and skeletal 
muscle protein metabolism. (4) Total energy expenditure and 
its relationship to protein metabolism and requirements. 

Nutrition and aging in skin derived cells — HNRCA, 12/11/89 to 

12/10/94: 624,554 
Objective: The overall objective is first to understand cutane- 
ous aging and the impact of nutritional intake or other 
modifiable environmental factors on this aging process and 
second to devise dietary or other strategies for reducing the 
negative impact of such factors on the completely defined 
culture systems for all skin derived cells; and analysis of the 
effect of various dietary antioxidants on UV-mediated cellu- 
lar damage (photoaging). 

Lipoproteins nutrition and aging— HNRCA, 12/11/89 to 12/10/94: 1,645,697 
Objective: Our research objectives are: (1) to test the efficiency 
of a low saturated fat low cholesterol diet in lowering densi- 
ty lipoprotein (LDL) cholesterol levels in elderly normal and 
hyperlowlipidemic subjects; (2) to study effects of dietary 
fatty acids on the production of liver lipoproteins in mon- 
keys. (3) to study the interrelationships of diet and lipopro- 
teins in the population; and (4) to study the regulation of in- 
testinal lipoprotein production by fatty acids and cholesterol 
in vitro in Caco-2 cells. 

Effect of nutrition and aging on eye lens proteins, proteases, and 
cataract— HNRCA, 12/11/89 to 12/11/94: 869,083 
Objective: One-half of the eye lens cataract operations and sav- 
ings of over $1 billion would be realized if we could delay 
cataract by 10 years. We are attempting to use enhancement 
of dietary antioxidants, such as vitamin C, and other nutri- 
ents such as carotones and folacin to delay damage to lens 
proteins and proteases and to maintain visual function in el- 
derly populations. This should delay (1) cataract-like lesions 
in eye lens preparations and (2) cataracts in vivo. 

Epidemiology applied to problems of aging and nutrition — HNRCA, 

12/11/89 to 12/10/94: 1,377,917 
Objective: To define diet and nutritional needs of older Ameri- 
cans. (2) To advance methods in nutritional epidemiology. (3) 
To relate nutrition to cataract formation and to the function 
of the aging kidney, skeletal system, and cardiovascular 
system. (4) To define the changes in body composition associ- 
ated with aging. (5) To interrelate physical activity and diet 
with the aging process. (6) To relate low levels of vitamin 
B12 with neurobehavioral and cognitive function. 

Trace element nutrition, neuropsychological function and behav- 
ior— GFNRC, 03/15/91 to 03/14/96: 607,218 
Objective: Identify and characterize the effects of marginal or 
subclinical deficiencies of biologically essential trace ele- 
ments (e.g., copper, iron, zinc) on neuropsychological func- 
tion and behavior relevant to the performance demands 
placed on adults in the United States. Provide information 
regarding trace element requirements for optimal mental 
function and emotional adjustment to promote the general 
psychological well-being of adults in our society. 

ECONOMIC RESEARCH SERVICE (ERS) 

Title and purpose of each program or activity which affects older Americans 

The Economic Research Service identifies research and policy issues relevant to 
the elderly population from the perspective of rural development. Several projects 



17 



investigate the importance of residential location on the elderly's health and use of 
health care services. We actively participate in the Interagency Forum on Aging- 
Related Statistics at the National Institutes of Health. We represent IRS on the 
Forum's Work Group on Older Americans in Rural Areas, a work group which pre- 
sented data on commonly-held beliefs about the rural elderly population in a brief- 
ing to the Senate Special Committee on Aging and staff. This presentation will also 
be presented at the annual meeting of the Gerontological Society of America in No- 
vember of 1992. We have also served on several Census Bureau advisory committees 
and reviewed tables for the forthcoming 1990 Census Subject Reports on the Elderly 
Population, and Housing of the Elderly Population. 

Brief description of accomplishments 

The following reports on the rural elderly have been prepared by our staff in the 
past year: 

Rogers, Carolyn C, "Health and Social Characteristics of the Nonmetro El- 
derly," in Proceedings OUTLOOK '92 and Agricultural Outlook '92 Chartbook 
(February 1992). 

Rogers, Carolyn C, et. al., "Common Beliefs About the Rural Elderly: Myth 
or Fact?" A Staff Report to the Special Committee on Aging, United States 
Senate, Serial No. 102-N (July 1992). 

Rogers, Carolyn C, et. al., "The Elderly in Rural America," a forthcoming 
report in the Vital and Health Statistics series from the National Center for 
Health Statistics (NCHS), Fall 1992. 

Rogers, Carolyn C, "Health Status and Use of Health Care Services by the 
Older Population in Nonmetro Areas: A Residential Comparison," a forthcom- 
ing RDRR, and "Health Status of the Older Population in Nonmetro Areas," a 
forthcoming article in Rural Development Perspectives. 
The following presentations on the rural elderly have been prepared by our staff 
in the past year: 

Rogers, Carolyn C, "Health and Social Characteristics of the Nonmetro El- 
derly," annual USDA Outlook Conference, December 4, 1991. 

Rogers, Carolyn C, et. al., "Ten Common Beliefs About Older Americans in 
Rural Areas: What Do National Data Tell Us?" a briefing for the Senate Spe- 
cial Committee on Aging and staff, as part of the Work Group on Older Ameri- 
cans in Rural Areas, August 7, 1992. 

Rogers, Carolyn C, "Transitions in Health Status and Living Arrangements 
of the Elderly, by Residential Location: 1984 to 1990", Southern Demographic 
Association annual meeting in October 1992. 

COOPERATIVE EXTENSION SYSTEM PROGRAM INITIATIVES WITH SENIOR 
CITIZENS, THEIR FAMILIES, CAREGIVERS AND THE AGING NETWORK 

During the past year, members of the 74 State, territorial, and trust Land Grant 
University network, and Extension Service, U.S. Department of Agriculture, have 
been engaged in the Senior Series, a national educational program initiative which 
has the following objectives: 

Provide information to help senior adults improve the quality of their physi- 
cal and mental health, strengthen their independence, and provide opportuni- 
ties that allow them to continue living in their home communities. 

Help build meaningful, long-range educational programs for senior adults and 
establish working relationships with appropriate agencies. 

Encourage use of the knowledge, talents and skills of senior adults through 
public service volunteer activities. 
Funding support has been provided by the W.K. Kellogg Foundation, Farm Foun- 
dation, and the U.S. Office of the Administration on Aging (AoA). The project is 
headquartered at the Center on Rural Elderly, University Extension, University of 
Missouri System, Columbia, Missouri, with the following Land Grant University en- 
tities serving as dissemination partners: Northeast Regional Center for Rural Devel- 
opment, Pennsylvania State University, Western Rural Development Center, 
Oregon State University, North Central Regional Center for Rural Development, 
Iowa State University, and the Southern Rural Development Center, Mississippi 
State University. Gerontological educational resource materials have been created; 
staff have been trained; and the following community-based action programs are un- 
derway. 



18 



NORTHEAST REGION 

Delaware 

Senior Series Volume 1, Caregiving, was shared with hospital instructors. Four 
Senior Series nutrition education workshops were held with 35 participants attend- 
ing each workshop. Fifteen hundred nutrition education newsletters were distribut- 
ed through various civic groups, Elderhostel and during the Nutrition Education 
workshops. 

Working in collaboration with Delaware Health and Social Services, the Kent 
County Home Economist is serving on a Continence Coalition project. Delaware 
Health and Social Services applied for a Division of Aging grant to initiate and 
evaluate a demonstration project on urinary incontinence. Plans are being made to 
utilize the Senior Series module, "Managing Incontinence for Healthy Aging-Blad- 
der" in senior centers and other community organizations to accomplish the public 
education portion of the project. This demonstration project will benefit the citizens 
of Delaware and also may serve as an intervention model for other states to devel- 
op. 

Senior Series nutrition education information was shared with the area agency on 
aging and the development and distribution of a nutrition series is planned. Senior 
Series materials also were used as a resource for an existing television program. At 
the Delaware State Health Fair, Extension worked with the area agency on aging 
using Senior Series resources. An intergenerational program also is in the planning 
stage. 

Maryland 

Current senior mailing lists were updated using information from senior citizen 
centers, the area agencies on aging, local churches, civic groups, senior housing com- 
plexes, meals on wheels, and health care professionals. Approximately 1,255 nutri- 
tion newsletters were directly distributed to seniors. Various agencies reproduced 
the newsletters and distributed an additional 200 copies. 

Fifty-five nutrition education workshops were held with a total of 1,063 partici- 
pants. Working with the area agency on aging, nutrition programming was planned. 
The programming was publicized with an Elderhostel and an adult day care center. 
The Somerset County home economist, served in an advisory role as a nutrition in- 
structor. Additionally, she incorporated Senior Series programming into twelve 
radio broadcasts of her existing Vz hour weekly program, "Nutrition and Health." 
This program has a listening audience of approximately 200,000. 

On August 13, 1992, the official ceremonial signing of the Memorandum of Under- 
standing between the Maryland Cooperative Extension Service (MCES) and the 
Maryland Office on Aging (MOA) was followed by a press conference to announce 
the Maryland Nutrition Screening Initiative. During FY 1993, MCES and MOA 
have teamed up for the Maryland Nutrition Screening Initiative. This is a national 
initiative which is a special project of American Academy of Family Physicians; the 
American Dietetic Association and the National Council on the Aging, Inc. Two 
University of Maryland specialists will provide major direction for this health initia- 
tive. 

New Jersey 

Five Enhancing Self-Care workshops were held, and 206 seniors participated. An 
Eldercare project in two counties resulted as a spin-off from the workshops. 

Using Senior Series materials and additional resources, a county home economist 
developed the curriculum, "It's Your Choice: Living Wills," which continues to be 
taught to groups in New Jersey. The area agency on aging publicized the Living 
Wills workshops. 

In five counties, the Nutrition Notions newsletters are being distributed to ap- 
proximately 300 people. Information from the Age Pages and the Food Safety and 
Nutrition sections of volume 2 are being used in the newsletters. 

In Warren County, a 6 week series, "Aging: Issues for Those Who Care," was re- 
cently completed. Twenty family caregivers and paid caregiver staff from two agen- 
cies were educated on a variety of topics. 

A Bergen County extension home economist used the Senior Series materials in 
the following ways: 10 families participated in the Grandletters program and an in- 
service workshop on stress reduction was conducted for 31 directors of nutrition cen- 
ters. 

New York 

Thirty seniors attended various mini-workshops: Fat & Fiber in the Diet; Improv- 
ing Communication Skills; Understanding the Changes Aging Brings. One Enhanc- 



19 



ing Self-Care workshop was held; twenty-four participants attended. Materials on 
topics such as Walking Programs, I Have a Right to Decide, and Medications have 
also been shared with elderly coalition members. An intergenerational project, 
Project E.A.S.E. (Exploring Aging Through Service Experiences), with 4-H clubs is 
being piloted in Washington County. 

In March 1992 Cornell Cooperative Extension of Nassau County began a unique 
working relationship with the Department of Senior Citizen Affairs through their 
seniormobile program. The seniormobile is a traveling information office that pro- 
vides professional staff and agency representatives to assist the elderly population 
of Nassau County in the communities in which they live. The seniormobile visits 
libraries, senior centers, parks and beaches. Senior Appreciation Days in coopera- 
tion with local banks provide an "open house" atmosphere while seniors can obtain 
information from staff and representatives. Since March, Extension staff and volun- 
teers have been a part of the seniormobile at 22 sites and have reached over 2,000 
consumers with information about extension resources and specific programs. 
Trained Cornell Cooperative Extension water volunteer educators have been present 
to discuss programs available and to share methods of home water conservation. 

Pennsylvania 

In the southeast region of Pennsylvania, several extension agents are using the 
Senior Series materials in the following ways: one agent reached approximately 65 
adults using the Volume 2 materials "Strategies for Successful Health" and "Tar- 
geting A Healthier Diet" and approximately 200 Nutrition newsletters were distrib- 
uted with the local meals on wheels; one extension home economist's newsletter in- 
cludes nutritional information, and she has been working with a personal care 
home supervisor in the areas of Nutrition for the Elderly and Special Diet Concerns, 
Understanding the Elderly (Sensory Loss, Dementia, etc.), Fire Safety for the Elder- 
ly, and Food Safety for the Elderly; twenty-five women participated in a workshop, 
highlighting the Food Safety module of "Enhancing Self-Care Among the Elderly." 
Two nutrition education workshops were held for civic groups, senior housing com- 
plexes, and health care professionals; a total of 57 participants attended. Also, work- 
ing with the area agency on aging, a Lebanon County extension agent, formed a 
Senior Series advisory committee, planned a Senior Series in-service day, and 
planned the recruitment and education of volunteers; the Elk county home econo- 
mist, worked with the director of a personal care home to help her improve her resi- 
dence and develop a better understanding of the special needs (physical, dietary, 
etc.) of older residents. For example, Sensory Losses and How to Cope with Them 
were addressed. Previously, the entrance hall to the home was extremely dark due 
to the dark woodwork, wallpaper and curtains covering the door window. For in- 
creased safety, the curtains were taken down to let the sunlight in. Also bedspreads 
that color contrast with the carpeting in the bedrooms have been purchased; this 
enables the older residents to distinguish the edge of the bed from the carpeting 
thereby helping to reduce the risk of falling. Safety rails and open shelving have 
been installed throughout the home, as well as emergency lighting in case of a 
power failure. 

Thiry-nine Cooperative Extension family living agents are now prepared to pro- 
vide training for administrators and staff of personal care homes throughout the 
commonwealth. These extension agents have been certified as approved trainers by 
the Pennsylvania Department of Public Welfare, which now requires forty hours of 
initial training and six additional hours of continuing education for administrators 
annually. Extension educators have been certified to provide eight hours of training 
in gerontology and mental health (the latter in collaboration with local mental 
health agencies) and four hours in nutrition, food handling, and sanitation. They 
are also prepared to offer training in a number of related areas to help administra- 
tors fulfill the continuing education requirements. Materials for trainers and par- 
ticipants were adapted for use in Pennsylvania from manuals entitled "Ensuring 
Quality Care for Residents and Caregivers," developed by an AO A funded project 
(#10AT0026) for adult foster care providers in Oregon. 

West Virginia 

West Virginia utilized the Enhancing Self Care and Nutrition Education re- 
sources in a senior health promotion program, Preventicare, which is being conduct- 
ed in nine counties. 

Five SOS, Seniors Outreaching Seniors, training sessions were held and reached 
75 participants. 



20 



SOUTHERN REGION 

Alabama 

An Elder Camp program in Calhoun County attracted 400 campers from 50 to 95 
years of age for its sixteenth anniversary 3-day event. Workshop presenters included 
the chairman of the Alabama Commission on Aging in the State's Silver Haired 
Legislature, the Director of the Auburn University Center on Aging and Center on 
Governmental Services. A county Extension home economist coordinated the camp. 

Extension faculty at Tuskeegee University planned and implemented a communi- 
ty-based Senior Olympics project, which in addition to competitive events, including 
activities designed to assess food intake, clothing choices, and simple exercises. 

Arkansas 

Senior Series activities were held throughout the state in order to achieve rapid 
dissemination of the geronotological educational resources to county extension staff. 
A series of four 1-day regional in-service training workshops (one in each of the four 
corners of the State) were held. The average attendance at each workshop was 30 
county staff members. 

The Senior Series manuals are being used extensively throughout the State with 
strong senior volunteer involvement and active co-sponsorship with aging-related or- 
ganizational and agency officials. 

Florida 

Faculty at the University of Florida and Florida A&M State University have cre- 
ated a faculty committee entitled the "Successful Aging Design Team" and this 
team has conducted a series of regional workshops throughout the state for county 
extension agents. The training sessions focused upon the usage of Volumes 1 (SOS 
for Caregivers); 2 (Enhancing Self Care); and 3 (Nutrition Education). Samples of the 
progress being made include: the county home economist in Homestead provided a 
3-hour bilingual training workshop to 50 adult volunteers, focusing on special nutri- 
tional concerns of the elderly. These volunteers were being trained by the Dade 
County Community Action Agency to become "Senior Companions," who assist 
homebound elderly with everyday activities in the home and assist at congregate 
meal sites. Senior Series information was used to provide information on factors af- 
fecting the nutritional needs of older adults; taking medications safely; nutritious 
and enjoyable meal preparation in single servings; as well as basic food and kitchen 
safety for the elderly. These volunteers, seniors themselves, were given a total of 8 
full days of training sessions on such topics as coping with Alzheimer's, AIDS, de- 
pression, elderly abuse, personal hygiene, and handling emergency situations. Half 
of the 50 volunteers were hispanic, 10 black and 4 males. 

The community action agency congregate meal sites are also reproducing the 
Senior Series nutrition newsletter, with over 650 copies distributed monthly to the 
homebound and to congregate nutrition sites throughout Dade County. The program 
directors found the newsletter especially effective when delivered with meals to the 
homebound elderly, and a suggestion was made that the newsletter be made avail- 
able in Spanish in order to reach over 175,000 Hispanic seniors. This resource ar- 
rived at a time when finances permitting senior centers to contract with dietitians 
were being eliminated, so the Senior Series Nutrition Module has been a very useful 
resource to many elderly nutrition program coordinators: eight meal site managers 
were trained to use the nutrition units and the newsletter; the newsletter (Volume 
3) has been mailed to 2,800 residents — and this is only in three counties; and in one 
county, thirteen employees of Community Care for the Elderly enrolled in training 
sessions for homemakers' services received information taken from the Senior 
Series on demographics of aging (Volume 5) and the Aging Process (Volume 1). 

The Extension home economist in Brevard County coordinated a "Caregivers Fes- 
tival" that was planned and conducted by 15 social service agencies. Over 150 care- 
givers participated. 

Georgia 

Following the Senior Series workshop at Fort Valley State College, three addition- 
al 1-day area training sessions were conducted across Georgia. Eight of the Exten- 
sion home economists who participated in the Fort Valley workshop acted as train- 
ers in these follow-up sessions, providing training for an additional 74 county home 
economists. Agents of this core group are now serving as area resource persons to 
other Extension personnel, cooperating groups and agencies. Plans are to expand 
the nutrition newsletter series and to begin statewide distribution in October, 1992 
through the 159 county Extension offices in the State. 



21 



Faculty at Fort Valley State College planned and conducted a volunteer training 
program for senior citizen volunteer leaders related to proper usage of medications 
and these volunteers are in the process of disseminating this information among the 
senior population in middle Georgia. Extension staff also conducted a Senior Citi- 
zens Day program on the campus of Fort Valley State College with proper use of 
medications as the program theme. Over 300 seniors from the mid-Georgia region 
participated in the programs. 

Kentucky 

In October 1990, the Senior Series was introduced to Kentucky through a state- 
wide "Challenges of Aging" workshop. Following this workshop, $5,000 of seed 
money was distributed by a competitive mini-grant process to 12 sites in Kentucky. 
The purpose of the seed money was to encourage implementation of projects taken 
from the Senior Series manuals or directly inspired by the Senior Series. During 
1991-92, local communities carried out the following projects: 

Senior Citizen's Horticulture Project — The County Extension Agent for Agricul- 
ture and the Senior Citizen's Center Director, along with a variety of community 
groups purchased and then constructed a 10x24' greenhouse. After construction 
was completed on the grounds of the Martin County Senior Citizen's Center, 50 sen- 
iors planted their own trays of vegetables and flowers. By early summer, the plants 
were transplanted into a donated plot of ground near the Senior Center. The flowers 
were subsequently replanted in front of the Senior Center and the bountiful harvest 
of vegetables were sold with the proceeds invested in the Senior Center program 
and services. 

Women's Financial Information — The Daviess County Extension Agent for Home 
Economics, was inspired by the Seniors Outreaching Seniors volume of the Senior 
Series. Based upon local needs, she decided to focus her educational outreach efforts 
on financial information for midlife and elderly women. Cooperators were groups 
such as the Daviess County Extension Homemakers and the Owensboro-Daviess 
County Committee on Aging. A series of four workshops were conducted to inform 
older women of their financial options and to empower them with the skills and 
self-confidence to make decisions on their own. Thirty-three older women participat- 
ed in the series of four in-depth workshops. 

Carter County Telephone Reassurance Program — The County Extension Agent for 
Home Economics established a volunteer task force to implement a telephone relay 
system to reach senior shut-ins on a daily basis. Cooperating individuals and organi- 
zations include Northeast Area Development Council, Department for Social Serv- 
ices, Bethany House Christian Service Center, the area agency on aging, home 
health agencies from three hospitals, Carter County Health Department, Senior 
Volunteer representatives, the Carter County Homemakers Association, the Depart- 
ment of Social Insurance, and the Kentucky State Police. 

The Owsley County Junior-Senior Olympics — The County Extension Agent for 4-H 
Youth Development, worked with a wide variety of local groups to establish Ken- 
tucky's first Junior-Senior Olympics. Senior citizens acted as organizers, encour- 
agers, scorekeepers, and judges for the 15 events. The day ended with an awards 
ceremony. Both the seniors and the youth were enriched by the intergenerational 
understanding and sharing that took place. 

Older- Adults and Kids Sharing — The Taylor County Extension Agent for Home 
Economics, worked in cooperation with the Lake Cumberland Health Promotion 
Program for Older Adults in establishing an intergenerational educational opportu- 
nity for senior adults and school-age children. The goal was two-fold: to enhance 
self-esteem and feelings of usefulness among senior adults as they share their 
knowledge, skills, and experiences with youngsters; and to enrich young children 
and give them positive experiences with senior adults. A large number of organiza- 
tions cooperated in offering a positive experiences with senior adults. A large 
number of organizations cooperated in offering a summer enrichment program that 
consisted of a series of one-day sessions at a variety of sites to acquaint children 
grades 4 through 6 with senior adults. The seniors provided the curriculum of herit- 
age skills, storytelling, cooking, farm visits, hobbies, crafts, and more. The youth en- 
joyed these educational experiences and developed positive and respectful attitudes 
toward older community members. 

Seniors Reaching Seniors — County Extension agents from ten counties in the 
Mammoth Cave area cooperated with numerous groups and individuals to offer a 
full day workshop in which senior volunteers served as facilitators and in some 
cases, workshop presenters. The workshop was designed as a general area-wide in- 
troduction to the Senior Series. Specific topics included intergenerational relation- 
ships, nutrition in later years, caring for the caregiver, and health fraud. The key- 



22 



note address focused on myths and facts about aging. Throughout the program, par- 
ticipants could visit fifteen exhibit booths which provided a wide array of education- 
al information. 

Clark County Intergenerational Project — A total of 80 Head Start children and 
190 Senior Citizens were involved in a series of programs designed to encourage 
shared experiences and growth in intergenerational understanding and communica- 
tion. Children visited local nursing homes and Senior Citizens Centers four times 
each. Together they made Valentines for the Middle East troops, colored Easter 
eggs, had an Easter bonnet parade, made baskets for delivery to 70 homebound pa- 
tients, and planted a tree and tulip bulbs at the new Generation Center. Seniors and 
children were able to interact positively through these activities. 

Perry County Senior Community Garden — The Agricultural Agent and the Home 
Economics Agent worked together with senior citizens and community groups in ac- 
complishing the following objectives with their Community Garden Project: provid- 
ed a money-saving endeavor; provided wholesome, health vegetables to eat; provided 
wholesome exercise experiences; learned about profit and loss; learned the value of 
vegetables grown and the importance of nutrition; and learned the latest planting, 
fertilizing, watering, insect disease, and harvesting techniques. 

Intergenerational Sharing through Puppetry — The Jefferson County Extension 
Agent for 4-H Youth Development and a veteran behavior disorders teacher worked 
together to launch this program. Its purpose is to support a group of students who 
are behavior-disordered by enabling them to develop puppetry skills which they in 
turn use to share with local elderly persons in nursing homes, hospitals, and VA 
center After undergoing approximately 2 months of preparation, the students took 
their puppetry show to a total of 40-50 nursing home residents that have been vis- 
ited thus far four times by the student group, the program is ongoing and will 
expand as need and resources dictate. 

Mississippi 

Work being done has these goals: (1) Seniors in Stone County to develop newslet- 
ter for distribution to seniors throughout the county, expanding to other counties 
served by AARP and AoA; (2) Seniors in the county to develop local history video 
library; (3) Seniors to develop weekly 15-minute radio program providing informa- 
tion to seniors and the general public; and (4) Seniors enlist the community to plan 
a Senior Fun Day in Stone County involving seniors from a four-county area, coordi- 
nated with AARP chapters. All of the projects are being coordinated and facilitated 
by senior adult volunteers. Interest remains high participation of seniors is strong 
and all organizational and agency co-sponsors are pleased with the progress. 

Oklahoma 

Extension specialists at Oklahoma State University have implemented a portion 
of Volume 1 (Health and Legal Decisions Facing Older Adults). County Home 
Economists in four counties have trained volunteer Extension Homemakers Club 
leaders to deliver a four-part series: (1) Medicare Round-Up and Patients Medical 
Rights; (2) Power of Attorney and Guardianships; (3) Will and Estate Planning, and 
(4) The Living Will. 

Langston University extension specialists have conducted training session on Vol- 
umes 1, 2, 3, and 4 at a workshop attended by 157 persons. Workshop participants 
included coworkers in the Youth at Risk Program, Area Nutrition Centers, Elder 
Care Staff (an agency of the County Health Department), Church Mission Society 
Group, Alpha Kappa Sorority, Retired Teacher's Group, and Wellness Center Staff. 

Tennessee 

A pilot project has been conducted in seven middle Tennessee counties. Trained 
elderly persons implemented a reading program designed to enhance literacy skills 
in preschool and kindergarten-age children. Elderly persons read to young children; 
used story telling and games and activities to encourage a desire to read and learn. 

WESTERN REGION 

Alaska 

The Extension home economists in Nome adapted nutrition materials from Senior 
Series Volume 3 for use in newsletters and 1,150 families were reached in 12 
Eskimo villages. The Extension home economist in Palmer shared information from 
Volume 1, SOS about Caregiver Legal Concerns with local Extension Homemaker 
Clubs and ten persons were reached. Four workshops were conducted using the Nu- 
trition and Diet module from Volume 2, Enhancing Self Care and 60 persons attend- 
ed. The Extension home economist in Anchorage presented 8 monthly workshops 



23 



from Volume 2. The Extension home economist in Juneau shared Volume 3, Nutri- 
tion Newsletters with Senior Center participants. The first edition of the newsletter 
has been mailed from the Extension office and additional newsletters will follow. 

Arizona 

Enhancing Self Care materials are being used for in-home caregiving classes. Nu- 
trition sites are using the Nutrition newsletters with over 500 seniors being reached. 
A home economist has begun a program utilizing Volume 4, Intergenerational Rela- 
tionships and the Kingman library is sponsoring a Senior utilizing Volume 4, Inter- 
generational Relationships and the Kingman library is sponsoring a Senior Listen- 
ing to After-School Children's Program in which senior volunteers listen to children 
read books. 

Colorado 

A week-long for-credit course for Cooperative Extension professionals was con- 
ducted at Colorado the University. The course was co-sponsored by Colorado State 
University Cooperative Extension and the Colorado and Wyoming Associations of 
Extension Home Economists. Nationally recognized professors from Colorado State 
University and Oregon State University taught about geriatric nutrition; Alzhe- 
imer's disease and caregiving; financial planning for later life; age-related changes 
in vision, hearing, thinking and memory; considerations in teaching older adults 
and families, and the aging network. 

Idaho 

Idaho Extension Home Economists are currently developing an agreement with 
the Department of Health and Welfare to conduct required training for Adult 
Foster Care personnel. Concepts from Volume 1, SOS, will be incorporated into the , 
training. Information from Volumes 1, 2, 3, and 4 was used in newsletters; four SOS 
training sessions were held, reaching approximately 65 caregivers; six workshops on 
nutrition were held, reaching 71 persons. 

Montana 

Senior volunteers were recruited for planning and implementing Volume 2, En- 
hancing Self Care; and a newsletter committee was formed for Volume 3, Nutrition. 
The following advisory groups have been formed: Ministerial Association for 
Volume 1, SOS; Local nursing home — Volume 2, Enhancing Self Care; and Senior 
Volunteers for Volume 3 will develop a newsletter. Information was shared from all 
Senior Series manuals with health care professionals, area agencies on aging, aging- 
related services, community professionals and with Extension co-workers at area 
Extension agents meetings. 

Five workshops have been conducted (1 per month) at a retirement home using 
materials in Volume 2, Enhancing Self Care manual. 

Two nutrition newsletters were adapted and distributed through senior citizen 
centers and the newsletter goes to everyone in the county who is 55 and older. 

Nevada 

Four workshops were conducted: 2 SOS; 1 Enhancing Self Care (reached 29); 1 In- 
tergenerational (reached 14). Five news articles were written using information in 
the Enhancing Self Care manual. Manuals were shared with area agency on aging 
officials, health care professionals, aging-related services, and community profes- 
sionals. 

New Mexico 

Information from Volumes 2 and 3 were used as a resource for newsletters. Infor- 
mation from Volume 1 SOS, was shared with 38 people. Three workshops were held 
using Volume 2, Enhancing Self Care and a total of 262 people attended the work- 
shops. Volume 4 — Intergenerational Relations: two youth-initiated programs were 
held with 2 seniors and 26 youth participating. Volume 5— Opportunities for Exten- 
sion, was shared with area agency on aging representative, who will use materials 
to train Senior Companions. Information from the Senior Series was presented to an 
RSVP and Senior Companion Group of both sexes and three ethnicities. 

Wyoming 

A 3-day statewide training workshop for 45 extension staff and professionals in 
the aging network was held in February in Casper, Wyoming. Twenty of Wyoming's 
23 counties were represented at the workshops. Exercises from the cultural diversity 
workshop on Native Americans was used to help resolve a conflict. Twenty-eight 
women were reached, and the conflict has been reduced. Fourteen workshops were 
conducted using Volume 2, Enhancing Self Care and 183 people were reached. Spin- 



24 



offs included a health lecture series and food safety program. Four Nutrition news- 
letters from Volume 3 were distributed to senior citizen centers and through the 
Extension Homemakers newsletter. A Visits to Remember training workshop was 
held for the community. Thirty-one persons learned how to improve their visits with 
nursing home residents and shut-ins. Stepping into the Past and Grandletters are 
being used with Extension Homemakers and 4-H Junior Leaders to promote inter- 
generational activities. 

NORTH CENTRAL REGION 

Illinois 

After the Senior Series regional training workshop, the following program devel- 
opment tasks are underway: A state Senior Series advisory team has been created 
to provide leadership to the project. Team members include extension county and 
state home economists and representatives from the state unit on aging, area agen- 
cies on aging, and the American Association of Retired Persons; An extension repre- 
sentative has been serving on a State Fair planning committee under the leadership 
of the state unit on aging organized for developing plans for activities for older 
adults at this summer's state fair. A committee of extension professionals is in- 
volved in planning and carrying out two primary projects: a large window display 
and a series of 15 minute presentations over a 10-day period. Senior Series materials 
will be used. An extension specialist is a member of the program committee plan- 
ning for the 1992 Illinois Governor's Conference. Senior Series has been the vehicle 
to increase the linkage of extension with the Illinois Department on Aging and; 
Nine fact sheets and two audio-cassette programs have been completed on caring for 
caregivers. Two new fact sheets are being initiated with a reorganized committee. 
This committee is also developing a new focus aimed at helping communities evalu- 
ate local responses and services for meeting the needs of older adults and care- 
givers. 

Indiana 

Working with the Indiana Higher Education Television System Purdue University 
Extension Specialists broadcast throughout the state, two 4-hour training programs. 
The training sessions featured Volumes 1 and 2 of the Senior Series. Thirty county 
home economics agents participated in the training. As a follow-up to the training 
assignment, each county home economics agent agreed to conduct two community- 
based action programs utilizing the information provided in the training workshops. 

Iowa 

Community-based projects which are underway include: pet therapy in nursing 
homes by youth; Senior citizen involvement in radio and TV; senior citizen prepara- 
tion of nutrition newsletters; meal site presentations of Volume 2 material; and 
Volume 1 information delivered to assisted care facility and an Indian settlement. 
Networking is occurring with AAA's, parish nurses, Senior Housing Project staff, 
congregate meal site coordinators, and volunteers. 

Minnesota 

Dakota County — Agent is working with a community committee (including senior 
representatives, senior center, public health, and extension) to develop a senior nu- 
trition newsletter. They expect the monthly newsletter to have 2,000 subscriptions. 
Former SNAP (Senior Nutrition Adult Program) volunteers will do the marketing 
and presenting demonstrations at various sites throughout the county. 

Missouri 

Using funds received from a grant from the Missouri Division of Aging, Universi- 
ty Extension has contracted with each AAA to work collaboratively with the paral- 
lel regional extension specialist to implement Senior Series in at least two localities 
in each of the 10 AAA regions. Presently, regional extension specialists and direc- 
tors of the AAA's are conducting a wide range of community-based and problem- 
focused projects in communities throughout the state. 

The Missouri Gerontology Institute conducted the 1992 Missouri Extension Insti- 
tute on Aging during the period May 31-June 5 on the campus of the University of 
Missouri-Columbia. The institute was co-sponsored with the W.K. Kellogg Founda- 
tion and the Farm Foundation. The academic curriculum focused upon aging proc- 
esses; nutrition, physical health and mental health issues; multi-cultural perspec- 
tives on aging; caregiving and intergenerational program opportunities; and public 
policy and community development issues, perspectives, and processes. Twenty ex- 
tension State and county specialists from eight different States, Puerto Rico and the 



25 



Virgin Islands participated in this 1-week residential gerontology graduate credit 
learning experience. 

Nebraska 

The program title for the Senior Series has been entitled "Senior Issues in Ne- 
braska." Each member of the team is conducting at least one Senior Series project 
in their Extension Program Planning Unit. Plans have been finalized for five dis- 
trict training and Senior Issues conferences involving local and regional agencies on 
aging, state health department, department of public institutions, department of 
gerontology at University of Nebraska at Omaha 4and the department of geriatrics 
at the University of Nebraska Medical Center. These conferences are emphasizing 
three tracks: training and information, one for extension staff and one for invited 
group of agencies; and a track for consumers. 

A monthly newsletter PRIME TIME is being circulated. A Senior Series letter- 
head has been developed and will be used to focus information to Extension staff 
monthly. The April Update inservice for all agents included four areas of training: 
an overview of Senior Series; an open house PENpages and Nebraska Resource Di- 
rectory training; a resource room; and distribution of a set of twenty ideas for core 
programming through Extension. 

North Dakota 

The project approach being used is multi-agency. The extension service, health de- 
partment and state agency on aging are working together to coordinate the project. 
A primary target audience is county commissioners. Four regional workshops were 
conducted which involved extension, county commissioners and county agencies, in- 
troducing them to Senior Series Volumes 1, 2, 3, and 4. Various members of the 
team served as trainers for the workshops as well as other qualified individuals. 

Ohio 

A major result of the Senior Series project is that it has fostered stronger working 
relationships between the Ohio Cooperative Extension Service, the Ohio Department 
of Aging, and the Area Agencies on Aging. This project is a truly cooperative effort 
with all three organizations contributing staff/ faculty and financial resources to the 
project. 

South Dakota 

Team members are piloting Volumes 1 through 4. The extension home economist 
team member is working to involve local Office of Adult Services and Aging social 
workers. The Volunteer Time Bank concept is being piloted in one area of the state 
under the leadership of a team member from the State Office of Adult Services and 
Aging. Planning for this effort is hoped to extend statewide. 

A two-day training workshop was conducted in two sites in June, 1992. Team 
members assisted in presenting programming ideas for Volumes 1 through 4 plus 
the Volunteer Time bank project. Coalition building, characteristics of the senior 
volunteer/ learner, and PENpages were also a part of the training curriculum. Each 
county in the State was invited to send a team comprised of extension staff; ASA 
social worker; and volunteer. Team members had an opportunity to develop action 
plans and submit proposals for start-up minigrants. A total of 18 minigrant projects 
are currently underway throughout the state. Funding for the project has come 
through AoA Eldercare Volunteer Corps and Community CARES grants. The Senior 
Series project is being used as a catalyst for expanded collaboration of services and 
broadening senior volunteer involvement throughout the state. 

Wisconsin 

The Senior Series materials were introduced by the training team to county-based 
and State faculty in February via the Education Television Network. 

The current goal of the team is to build coalitions with agency personnel, volun- 
teers and county-based faculty, ultimately seeing that materials get the broadest 
possible usage. 

Extension Service /National Association of County Officials (NACo) National 
Video conference. 

On July 9, 1992, the Extension Service/U.S. Department of Agriculture and the 
Land Grant University Cooperative Extension Services co-sponsored with NACo, the 
U.S. Department of Transportation; IBM; and the U.S. Administration on Aging 
(AoA), a 6-hour national videoconference which originated from NACo's annual con- 
ference in Minneapolis, Minnesota where 2,000 attendees participated. 

The goal of the national videoconference was to assist county governments meet- 
ing the challenges and opportunities resulting from America's rapidly increasing 



26 



aging population and deteriorating infrastructures. The specific objectives for the 
viewers/participants which were county commissioners, local aging-related organiza- 
tion/agency staff; community leaders; and senior citizens included: increase aware- 
ness of the challenges and opportunities resulting from America's aging population 
and aging infrastructure; begin to plan and implement effective strategies, policies; 
and programs that respond to these critical issues; and be motivated to act — to 
begin now to invest in the future by developing and implementing programs that 
will address priority aging population and infrastructure concerns of their commu- 
nities. < 

The videoconference was transmittedUo 200 downlink locations in 26 States and 
the U.S. Department of Agriculture involving 1,000 participants. 

Submitted by Leo L. Cram, Ph.D., Director Special Projects, CES, University of Missouri and 
Jeanne M. Priester, National Program Leader, Extension Service, U.S. Department of Agricul- 
ture. 

FARMERS HOME ADMINISTRATION 

Title and purpose statement of each program or activity which affects older Ameri- 
cans 

Currently FmHA has two programs that directly affect older Americans: 

Federal Domestic Assistant (FCA) catalog number 10.415 Rural Rental Hous- 
ing (RRH) Loans empower the agency authorized under the Housing Act of 1949 
as amended, Section 515 and 521, Public Law 89-117, 42 U.S.C. 1485, 1490a to 
make RRH loans. The objectives of this program are to provide and construct 
rental and cooperative housing and related facilities suited for dependent living 
for rural residents. Occupants must be low-to-moderate income families, elderly 
(62 years or older) or disabled. 

During fiscal year 1990, OBPA records show $571,903,000 was obligated to 
this program, and fiscal year 1991, $571,334,000; $573,900,000 was allocated for 
fiscal year 1992 and 1993 for the 515 program. 

The second program, FDA 10.417 Very Low-Income Housing Repair Loans 
and Grants (Section 504, Rural Housing Loans and Grants) is also authorized 
under the Housing act of 1949, its particular title is Title V, Section 504, as 
amended, Public Law 89-117, 89-754, and 92-310, 42 U.S.C. 1474. The objectives 
are to give very low-income rural homeowners an opportunity to make essential 
repairs to their homes to make them safe and to remove health hazards to the 
family or to the community. Applicants must own and occupy a home in a rural 
area and be without sufficient income to qualify for a section 502 loan under 
the FmHA regular housing program. To be a grant recipient, the applicant 
must be 62 years of age. 
Funds allocated and expended under this program were. — (Loans) fiscal year 

1990— $11,558,404; fiscal year 1991— $11,195,590; fiscal year 1992— $11,329,500; 

(Grants) fiscal year 1990— $12,642,930; and fiscal year 1991— $12,743,040; and fiscal 

year 1992— $12,804,300. 

Brief description of accomplishments 

In fiscal year 1991, 375 elderly projects were funded under the Rural Rental Hous- 
ing Loan Program. 

Under the Very Low Income Housing Repair Loans and Grants, 2,996 loans and 
3,664 grants were made in Fiscal Year 1990. In Fiscal Year 1991, 2,951 loans and 
3,695 grants were made. In fiscal year 1992, 2,857 loans and 3,678 grants were made. 

FOOD AND NUTRITION SERVICE (FNS) 

Title and purpose statement of each program or activity which affects older Ameri- 
cans 

The Food Stamp Program provides monthly benefits to help low-income families 
and individuals purchase a more nutritious diet. In Fiscal Year 1991 $17.3 billion in 
food stamps were provided to a monthly average of 22.6 million persons. 

Households with elderly members accounted for approximately 20 percent of the 
total food stamp caseload in fiscal year 1989. However, since these households were 
smaller on average and had relatively higher net income, they received only 7.9 per- 
cent of all benefits issued. 

Brief description of accomplishments 

The Food and Nutrition Service (FNS) continues to work closely with the Social 
Security Administration (SSA) in order to meet the legislative objectives of joint ap- 
plication processing for Supplemental Security Income households. 



27 



In response to the recommendations of recent FAO audit report, FNS and SSA 
have formed a workgroup which is now conducting monthly meetings with the goal 
of addressing the failures and inadequacies of the current joint processing system. 
Options for addressing joint processing problems are being developed. 

The Supplemental Security Income Modernization Project, which was initiated by 
the Social Security Administration in order to review and study the Supplemental 
Security Income Program, recently issued its final report. The report included two 
recommendations to improve the "linkage" between SSI and the Food Stamp Pro- 
gram. The recommendations were to develop a short food stamp application form 
for use in joint processing and to eliminate categorical eligibility in the food stamp 
program when recipients' SSI benefits reach the poverty level. FNS is preparing a 
response to the Modernization Project's recommendations. 

Title and purpose statement of each program or activity which affects older Ameri- 
cans 

The Food Distribution Program for Charitable Institutions and Summer Camps 
provides commodities to nonprofit charitable institutions serving the needy. Eligible 
charitable institutions include nonpenal, noneducational, nonprofit organizations 
such as homes for the elderly, congregate meals programs, hospitals and soup kitch- 
ens. 

It is thought that a large proportion of the beneficiaries of this program are elder- 
ly, but accurate estimates are no.t available. 

Brief description of accomplishments 

In 1991, total cost for the program was about $93 million. 

Title and purpose statement of each program or activity which affects older Ameri- 
cans 

The Commodity Supplemental Food Program provides supplemental foods, in the 
form of commodities, and nutrition education to infants and children up to age 6, 
pregnant, postpartum or breastfeeding women, and elderly who have low incomes 
and reside in approved project areas. 

Service to elderly began in 1982 with pilot projects. In 1985, legislation allowed 
the participation of older Americans outside the pilot sites if available resources 
exceed those needed to serve women, infants and children. In Fiscal Year 1991, $16 
million was spent on the elderly component. 

Brief description of accomplishments 

About 23 percent of total program spending provides supplemental food to ap- 
proximately 110,000 elderly participants a month. Older Americans are served by 12 
of the 20 State agencies. 

Title and purpose statement of each program or activity which affects older Ameri- 
cans 

The Food Distribution Program on Indian Reservations provides commodity pack- 
ages to eligible households, including household with elderly persons, living on or 
near Indian reservations. Under this program, commodity assistance is provided in 
lieu of food stamps. 

Approximately $23 million of total costs went to households with at least one el- 
derly person. (This figure was estimated using a 1990 study that found about 39 per- 
cent of FDPIR households had at least one elderly individual.) 

Brief description of accomplishments 

This program serves approximately 51,000 households with elderly participants 
per month. 

Title and purpose statement of each program or activity which affects older Ameri- 
cans 

The Child and Adult Care Food Program provides Federal funds to initiate, main- 
tain, and expand nonprofit food service for children and elderly or impaired adults 
in nonresidential institutions which provide child or adult care. The program en- 
ables child and adult care institutions to integrated nutritious food service with or- 
ganized care services. 

The adult day care component permits adult day care centers to receive reim- 
bursement of meals and supplements served to persons 60 years or older and to 
functionally impaired adults. An adult day care center is any public or private non- 
profit organization or any proprietary Title XIX or Title XX center licensed or ap- 
proved by Federal, State or local authorities to provide nonresidential adult day 



65-505 - 93 - 2 



28 



care services to eligible adults. In Fiscal Year 1991, $10.9 million was spent on the 
adult day care component. 

Brief description of accomplishments 

The adult day care component of CACFP served approximately 11 million meals 
and supplements to over 26,000 participants a day. 

A study of adult day care is currently underway in the Office of Analysis and 
Evaluation. The objectives of this study are to: (1) describe the characteristics of the 
adults and the adult day care centers participating in the adult day care component 
of CACFP; (2) compare participating centers and adults to centers and adults not 
participating in the Program; (3) determine participants' dietary intakes; and (4) 
project potential future Program growth. 

Title and purpose statement of each program or activity which affects older Ameri- 
cans 

The Emergency Food Assistance Program (TEFAP) provides nutritional assistance 
in the form of commodities to emergency feeding organizations for distribution to 
low-income households for household consumption or for use in soup kitchens. 

Approximately $101 million in commodities were distributed to households headed 
by the elderly. (This figure is estimated using a 1986 survey indicating that about 38 
percent of TEFAP households have members 60 years of age or older.) 

Brief description of accomplishments 

About 38 percent of the households receiving commodities under this program 
had at least one elderly individual. 

Title and purpose statement of each program activity which affects older Americans 
The Nutrition Program for the Elderly (NPE) provides cash and commodities to 
States for distribution to local organizations that prepare meals served to elderly 
persons in congregate settings or delivered to their homes. The program promotes 
good health through nutrition assistance and by reducing the isolation of old age. 
USDA supplements funding from the Department of Health and Human Services' 
Administration on Aging with cash and commodities provided on a per meal basis. 

Brief description of accomplishments 

In Fiscal year 1991 over 240 million meals were reimbursed at a total program 
cost of almost $139 million. On an average day approximately 925,000 meals were 
provided at over 14,000 sites. 

FOOD SAFETY AND INSPECTION SERVICE (FSIS) 

Title and purpose statement of each program or activity which affects older Ameri- 
cans 

FSIS is continuing a consumer education campaign targeted to older Americans, 
one of several groups of people who face special risks from foodborne illness. The 
goal is to reduce the incidence of foodborne illness due to consumer mishandling of 
food. Foodborne illness can lead to serious health problems and even death for a 
person who is chronically ill or has a weakened immune system. The elderly, with 
more than 35 million people in their ranks, are the largest group at risk and are 
increasing in number due to advances in medicine. 

Brief description of accomplishments 

Issues of FSIS' FOOD NEWS FOR CONSUMERS magazine contained articles de- 
tailing how foodborne illness affects those at-risk and how to prevent it. Reprints of 
these articles were made available to organizations representing or providing serv- 
ices to the elderly. 

Additional materials were distributed at appropriate conventions such as the 
American Public Health Association, the American Dietetic Association and the As- 
sociation of Long-Term Care Providers. 

FOREST SERVICE 

Title and purpose statement of each program or activity which affects older Ameri- 
cans 

The Department of Agriculture, Forest Service, in cooperation with the Depart- 
ment of Labor, sponsors the Senior Community Service Employment Program 
(SCSEP), which is authorized by Title V of the Older Americans Act, as amended. 
The SCSEP has three fundamental purposes: (1) part-time income for disadvantaged 
persons aged 55 and over, (2) training and transition of participants to the private/ 



29 



public sector labor markets; and (3) community services to the general public. This 
program employs economically disadvantaged persons age 55 and older in 38 States, 
the District of Columbia, and Puerto Rico. The SCSEP seeks to improve the welfare 
of underprivileged, low-income elderly, and to foster a renewed sense of self-worth 
and community involvement among the rural elderly. 

* Program participants are involved in projects conducted by the Forest Service 
such as construction, rehabilitation, maintenance, and natural resource improve- 
ment work. Participants receive at least the minimum wage to supplement opportu- 
nity to have participants regain a sense of involvement with the mainstream of life 
through meaningful work. Additionally, valuable conservation projects are complet- 
ed on National Forest lands. 

Brief description of accomplishments 

The Service's Interagency Agreement for July 1, 1991 to June 30, 1992, provided 
$25.8 million which employed an estimated 5,600 seniors; 22 percent were minori- 
ties, and 40 percent were women. Sixteen percent of the participants were later 
placed in nonsubsidized jobs. The Government reaped a return of $1.57 for each 
dollar invested in this program. 

Title and purpose statement of each program or activity which affects older Ameri- 
cans 

The Volunteer in the National Forests Program offers individuals from all walks 
of life the opportunity to donate their services to help manage the nation's natural 
resources. This program continues to grow in popularity as people realize how they 
can personally help carry out natural resource programs. Volunteers assist in 
almost all Forest Service programs or activities except law enforcement. They may 
choose to work in an office at a reception desk, operate a computer terminal, or con- 
duct natural history walks and auto tours. Volunteers may also be involved in out- 
door work such as building trails, maintaining campgrounds, improving wildlife 
habitat and serving as a host at a campground. 

Brief description of accomplishments 

During fiscal year 1991, 11,740 persons aged 55 and above volunteered their serv- 
ices in the National Forest. 

ITEM 2. DEPARTMENT OF COMMERCE 

December- 16, 1992. 

Dear Mr. Chairman: Thank you for your letter regarding the Department f Com- 
merce programs pertaining to the older Americans. 

We are enclosing our report for 1992 for inclusion in "Developments in Aging," 
Volume II. The report includes programs relevant to the older population. 

If you need further information, please have a member of your staff call Mr. Paul 
Powell, Bureau of the Census, Office of Congressional Affairs, on (301) 763-2446. 
Sincerely, 

Barbara Hackman Franklin. 

Enclosure. 

Bureau of the Census — Current Population Reports — 1992 



Series P-20 (Population Characteristics): Number 

Geographical Mobility: March 1990 to 1991..... 463 

Educational Attainment in the United States: March 1991 and 

1990 462 

Marital Status and Living Arrangements: March 1991 461 

School Enrollment — Social and Economic Characteristics of 

Students: October 1990 460 

The Asian and Pacific Islander Population in the United 

States: March 1991 and 1990 459 

Household and Family Characteristics: March 1991 458 

Residents of Farms and Rural Areas: 1990 457 

The Hispanic Population in the United States: March 1991 455 

Fertility of American Women: June 1990 454 

Voting and Registration in the Election of November 1990 453 

The Black Population in the United States: March 1990 and 

1989 448 

Series P-23 (Special Studies): 

Sixty-Five Plus in America 178 



30 



Population Trends in the 1980s 175 

Subject Index to Current Population Reports 174 

Population Profile of the United States: 1991 173 

The Hispanic Population of the U.S. Southwest Borderland 172 

Computer Use in the United States: 1989 171 

Studies in Household and Family Formation 169 

Perspectives on Migration Analysis 166 

Changes in American Family Life 163 

Studies in Marriage and the Family 162 

Migration Between the United States and Canada 161 

Labor Force Status and Other Characteristics of Persons with 

a Work Disability: 1981 to 1988 160 

Household After-Tax Income: 1986 157 

America's Centenarians (Data from the 1980 Census) 153 

County Intercensal Estimates by Age, Sex, and Race: 1970-80 ... 139 
Demographic and Socioeconomic Aspects of Aging in the 

United States 138 

Lifetime Work Experience and its Effect on Earnings: Retro- 
spective Data from the 1979 Income Survey Development 

Program 136 

Series P-25 (Population Estimates and Projections): 

Population Projections of the United States, by Age, Sex, Race 

and Hispanic Origin: 1992 to 2050 1092 

Projections of the Voting-Age Population for States: November 

1992 1085 

Estimates of Households by Age of Householder, and Tenure 

for Counties: July 1, 1985 1070-RD-2 

State Population and Household Estimates: July 1, 1989 1058 

U.S. Population Estimates, by Age, Sex, Race, and Hispanic 

Origin: 1989 1057 

Projections of the Population of States, by Age, Sex, and Race: 

1989 to 2010 1053 

United States Population Estimates, by Age, Sex, Race, and 

Hispanic Origin with Components of Change: 1980 to 1988 1045 

State Population and Household Estimates, With Age, Sex, and 

Components of Change: 1981-88 1044 

Population Estimates by Race and Hispanic Origin for States, 

Metropolitan Areas, and Selected Counties: 1980 to 1985 1040-RD-l 

Series P-60 (Consumer Income): 

Studies in the Distribution of Income 183 

Measuring the Effect of Benefits and Taxes on Income and 

Poverty: 1979-1991 182-RD 

Poverty in the United States: 1991 181 

Money Income of Households, Families, and Persons in the 

United States: 1991 180 

Workers with Low Earnings: 1964-1990 178 

Trends in Relative Income: 1964 to 1989 177 

Child Support and Alimony: 1989 173 

Trends in Income by Selected Characteristics: 1947 to 1988 167 

Earnings of Married-Couple Families: 1987 165-RD-l 

Series P-60 (Consumer Income): 

Characteristics of Households and Persons Receiving Selected 

Noncash Benefits: 1985 155 

Lifetime Earnings Estimates for Men and Women in the 

United States: 1979 139 

Series P-70 (Household Economic Studies): 

Who's Minding the Kids? Child Care Arrangements: Fall 1988.. 30 

Health Insurance Coverage: 1987-90 29 

Who's Helping Out? Support Networks Among American Fam- 
ilies: 1988 28 

Extended Measures of Well-Being: Selected Data from the 1984 

Survey of Income and Program Participation 26 

Pensions: Worker Coverage and Retirement Benefits, 1987 25 

Transitions in Income and Poverty Status: 1987-88 24 

Household Wealth and Asset Ownership: 1988 (Data from the 

Survey of Income and Program Participation) 22 



31 



What's it Worth? Educational Background and Economic 

Status: Spring 1987 21 

The Need for Personal Assistance with Everyday Activities: 

Recipients and Caregivers 19 

Spells of Job Search and Layoff . . . and Their Outcomes 16-RD-2 

Disability, Functional Limitation, and Health Insurance Cover- 
age: 1984/1985 8 

Current Housing Reports 

Series H-lll: 

Housing Vacancies and Homeownership: Third Quarter, 1992 ... 91-1 
Series H-121: 

Who Can Afford to Buy a House 91-1 

Home Alone in 1989 92-4 

Series H-123 

Housing in America: 1989/90 91-1 



OTHER REPORTS, PAPERS, DATA BASES, AND CONTINUING WORK 

I. The Federal Interagency Forum on Aging-Related Statistics 

The Census Bureau is one of the lead agencies in The Federal Interagency Forum 
on Aging-Related Statistics (The Forum), a first-of-its-kind effort. The Forum encour- 
ages cooperation among Federal agencies in the development, collection, analysis, 
and dissemination of data pertaining to the older population. Through cooperation 
and coordinated approaches, The Forum extends the use of limited resources among 
agencies through joint problem solving, identification of data gaps, and improve- 
ment of the statistical information bases on the older population that are used to set 
the priorities of the work of individual agencies. The participants are appointed by 
the directors of the agencies and have broad policymaking authority within the 
agency. Senior subject-matter specialists from the agencies are also involved in the 
activities of The Forum. The Forum was cochaired in 1992 by Barbara Everitt 
Bryant, Director, Bureau of the Census; Manning Feinleib, Director, National 
Center for Health Statistics; and Gene D. Cohen, Acting Director, National Institute 
on Aging. 

At the initial meeting of The Forum, held October 24, 1986, it was agreed that 
The Forum would work on the following activities: (1) identify data gaps, potential 
research topics, and inconsistencies among agencies in the collection and presenta- 
tion of data related to the older population; (2) create opportunities for joint re- 
search and publications among agencies; (3) improve access to data on the older pop- 
ulation; (4) identify statistical and methodological problems in the collection of data 
on the older population and investigate questions of data quality; and (5) work with 
other countries to promote consistency in definitions and presentation of data on 
the older population. 

The work of The Forum facilitates the exchange of information about needs at the 
time new data are being developed or changes are being made in existing data sys- 
tems. It also promotes communication between data producers and policymakers. 

As part of The Forum's work to improve access to data on the older population, 
the Census Bureau publishes a newsletter, "Data Base News in Aging," which 
brings news of recent developments in data bases of interest to researchers and 
others in the field of aging. All Federal agencies are invited to contribute to the 
newsletter, which is issued periodically. 

The Census Bureau released a report titled "Federal Forum Report 1989-90" in 
March 1992, which reviews the activities of The Forum and its member agencies 
during 1989-90. Various sections of the report summarize Forum work and accom- 
plishments, cooperative efforts of members, publications by member agencies, and 
activities planned for the near future. A telephone contact list of specialists on sub- 
jects related to aging is also included. 

The Census Bureau published a report of the Income Working Group of the Feder- 
al Interagency Forum on Aging-Related Statistics in June 1990, "Income Data for 
the Elderly: Guidelines." The report recommends ways in which data-collecting 
agencies can improve the comparability, quality, and usefulness of the income data 
collected across surveys. The report also discusses uses of income data, important 
sources of income for the elderly, and suggests a core set of information on income 
that all surveys with income data should collect, as well as a more extensive set of 
income items that survey designers may consider including. The Census Bureau has 
also published the "Inventory of Data on the Oldest Old," which is a reference docu- 



32 



ment of Federal data bases on the oldest old population. The above reports are 
available from Arnold A. Goldstein, Population Division, Bureau of the Census, 
Washington, DC 20233. Additional reports of The Forum's work groups are available 
from the National Center for Health Statistics. 

Census Bureau staff cochair the Working Group on Data on Minority Aging. The 
group is making an inventory of Federal and other large data sets to identify the 
extent to which data are available on minority groups in the older population. 
Census Bureau staff provided data and written materials for the Working Group on 
Older Americans in Rural Areas. This group briefed Congressional staff on whether 
available data support common beliefs about the rural elderly. Census Bureau staff 
also cochair the Working Group on Administrative Data on Aging. This group is 
considering the strength of administrative record data, particularly from Medicare 
files, as an input to estimating the very old population. 

II. Projects Between the Census Bureau and the Administration on Aging 

From the 1990 census, the Census Bureau plans to produce special tabulations 
particularly useful to local Area Agencies on Aging for administering programs 
under the Older Americans Act. The Census Bureau also plans to produce a 1990 
census subject report, "The Older Population in the United States," with informa- 
tion published in printed form at the national level and on computer files (magnetic 
tapes and compact disks) for States. The Census Bureau will also prepare a 1990 
census public-use microdata file with individual questionnaire information (to pro- 
tect respondents' confidentiality, the records contain no identifying information) for 
3 percent of persons aged 60 and over and members of their households. 

A "Guide to 1980 Census Data on Elderly" was published in 1986. This guide ex- 
plains how to locate census data on the older population. The report reviews census 
products, services, and explains how to obtain them. The report has table outlines 
from the census publications and summary tape files to show the specific form of 
data available about the older population. 

III. Projects Between the Census Bureau and the National Institute on Aging 

A. The Census Bureau published a report titled, "Sixty-Five Plus in America," 
Series P-23, No. 178. This report is a chartbook and analysis of demographic, social, 
and economic trends among the older population. The data used in this report are 
primarily from the 1990 Census of Population and Housing and national surveys 
such as the Current Population Survey, the Survey of Income and Program Partici- 
pation, the Health Interview Survey, and the Longitudinal Survey on Aging. This 
report summarizes numerous reports prepared by statisticians from the Census 
Bureau and other Federal agencies with information about the elderly. It also in- 
cludes information not previously released. This report expands on information in 
"Diversity: the Dramatic Reality" by Cynthia M. Taeuber, Chapter 1 of "Diversity 
in Aging ' Scott A. Bass, Elizabeth A. Kutza, Fernando M. Torres-Gil, eds., (Glen- 
view, IL, Scott, Foresman and Co., 1990). 

B. The Census Bureau published a wall chart titled "Elderly in the United 
States." This wall chart was produced by Cynthia Taeuber and Barry Ocker with 
the support of the Office of the Demography of Aging of the National Institutes on 
Aging (NIA). The statistics shown in the wall chart are intended to highlight dimen- 
sions of aging in American States. Data are primarily from the 1990 Census of Pop- 
ulation. Projections for the United States and States are from Series A issued in 
1990 and are available only through 2010. 

C. The Census Bureau published the first two of a series of "Profiles of America's 
Elderly." These profiles are titled "Growth of America's Elderly in the 1980's," and 
"Growth of America's Oldest-Old Population." These 2-page profiles include demo- 
graphic, social, and economic trends among the elderly. These profiles also include 
topics on demographic changes during the 1980's, racial and ethnic characteristics, 
and characteristics of the centenarian population. Additional profiles that will 
follow in this series will include international comparisons of older populations. 

D. "The 1990 Census and the Older Population: Data for Researchers, Planners, 
and Practitioners," by Cynthia M. Taeuber and Arnold A. Goldstein, summarizes 
the availability of 1990 census data on topics of interest to researchers on the older 
population. 

E. The Census Bureau prepared special tabulations from the 1980 census for the 
National Institute on Aging. These tabulations include selected tables from Summa- 
ry Tape File 5 retabulated with 5-year age groups from 60 years to 85 years and 
over. These tabulations also include other selected tabulations from the 1980 census. 
The University of Michigan archives these tabulations (Nancy Fultz, 313-763-5010). 



33 



F. The Census Bureau developed an international data base on the older popula- 
tion. The University of Michigan archives this data base (Nancy Fultz, 313-763- 
5010). 

G. Cynthia Taeuber wrote a chapter on the quality of census data on the elderly 
that includes an evaluation of coverage, age misreporting, estimates, and projections 
of centenarians, and so forth. It is "Types and Quality of Data Available on the El- 
derly in the 1990 Census," in "Epidemiology Study of the Elderly," ed. Robert B. 
Wallace, New York: Oxford University Press, 1992. 

H. The Census Bureau prepared a file from the Survey of Income and Program 
Participation (SIPP) on the health, wealth, and economic status of the older popula- 
tion. The SIPP file is archived at the University of Michigan (Nancy Fultz, 313-763- 
5010). 

I. Cynthia Taeuber (with Jessie Allen) wrote "Women in our Aging Society: The 
Demographic Outlook," in "Women in the Frontline: Meeting the Challenge of an 
Aging America," ed. by Alan Pifer and Jessie Allen, forthcoming from The Urban 
Institute, Washington, DC, 1993. The chapter looks at the demographics of popula- 
tion aging and its present and future intersection with various aspects of the experi- 
ence of American women. 

J. The Census Bureau provided The Forum with special tabulations on poverty of 
nonmetropolitan elderly (from 1989 Current Population Survey). 

K. "A Demographic Portrait of America's Oldest Old" was prepared by Cynthia 
M. Taeuber, Bureau of the Census, and Ira Rosenwaike, University of Pennsylvania, 
in "The Oldest Old," ed. by Richard Suzman and David Willis, Oxford University 
Press, 1992. This chapter looks at the rapid growth of the oldest old population, 
those 85 years and over and the reasons for that growth. This chapter also: (1) com- 
pares the oldest old's demographic, social, and economic characteristics with those 
of the younger old; (2) describes the characteristics of the centenarian population; (3) 
examines the quality of census data on the oldest old; and (4) discusses the implica- 
tions of the growth and characteristics of this unique and important group. 

L. The Census Bureau reprogrammed the regularly published tabulations of the 
Current Population Survey to include data for the population "65 to 74 years" and 
"75 years and over" in annual reports (see especially P-20, Nos. 461 and 458, P-60, 
Nos. 181 and 180). The report on marital status includes data for the population 85 
years and over. 

IV. International Research on Aging 

A. Studies from the International Data Base on Aging: 

1. The CIR and the Population Division updated the 1987 publication, "An 
Aging World." The new report, "An Aging World II," assesses demographic, 
social, economic, and health trends from recent population censuses and sur- 
veys. The report also emphasizes a number of additional topics: the oldest old; 
aging in Eastern Europe; health and disability-free life expectancy; and institu- 
tionalization and other living arrangements. Expected release date is March 
1993. 

2. The CIR is preparing a report for publication focussing specifically on popu- 
lation aging in Eastern Europe and the former Soviet Union. Topics include 
basic demographic trends, health status, and various socioeconomic dimensions 
of the elderly in this region of the world. Release is expected in mid-1993. 

3. The CIR completed updates for the original 42 countries in the Internation- 
al Data Base on Aging and added 12 countries to the data base. Additional 
countries are being incorporated on a flow basis. 

4. An updated version of the paper, "Living Arrangements of the Elderly and 
Social Policy: A Cross-National Perspective," by Kevin Kinsella of the Census 
Bureau was presented at the International Conference on Population Aging in 
San Diego, September 17-19, 1992. The paper examines family and household 
structure, changes over time, and potential implications for social support and 
expenditures. 

5. The CIR is preparing a report, "Population and Health Transitions." It 
looks at aspects of the demographic and epidemiologic transitions in Eastern 
Europe and the developing world, and discusses several implications for health 
policy. Expected release date is January 1993. An excerpt of this report was pre- 
sented at the Nations Expert Group Meeting on Population Growth and Demo- 
graphic Structure in Paris, November 16-20, 1992. 

6. "Population Aging in Africa: The Case of Zimbabwe," appeared in "Chang- 
ing Population Age Structures. Demographic and Economic Consequences and 



34 



Implications," published by the United Nations Economic Commission for 
Europe (Geneva) in 1992. Kevin Kinsella is the author. 

7. The CIR issued two briefs in its "Aging Trends" series, one on Hungary 
and one on the Baltic nations of Latvia, Lithuania, and Estonia. 

8. "Demographic and Health Dimensions of Population Aging in Latin Amer- 
ica and the Caribbean," by Kevin Kinsella of the Census Bureau, is a chapter in 
the forthcoming Pan American Health Organization publication, "Elderly Care: 
A Challenge for the 90's." 

9. "Research on the Demography of Aging in Developing Countries," by 
Kevin Kinsella of the Census Bureau, and Linda Martin of the National Acade- 
my of Sciences, was presented at the Workshop on the Demography of Aging, 
Committee on Population, National Academy of Sciences, Washington, DC, De- 
cember 10-11, 1992. 

10. The "Journal of Cross-Cultural Gerontology" began including an Aging 
Trends report in each of its quarterly issues. In 1992, reports on Kenya, Jamai- 
ca, Thailand, and Hungary appeared in the journal. The authors are Kevin Kin- 
sella, Heather Francese, and Victoria Velkoff of the Census Bureau. 

11. "Demographic Dimension of Population Aging in Developing Countries," 
by Kevin Kinsella of the Census Bureau and Richard Suzman of the National 
Institute on Aging, is a chapter in the "Journal of Human Biology," Vol. 4, 
pages 3-8, 1992. In this chapter, several demographic aspects of population 
aging in developing countries are considered: the oldest old, median population 
age; life expectancy and mortality; functional status and disability, and sex dif- 
ferences. While our understanding of the demographic impact of population 
aging is becoming better appreciated, research on the descriptive epidemiology 
of age-related changes in health and physical functioning in developing coun- 
tries is still at an early stage. 

12. "Population Dynamics of the United States and the Soviet Union," was 
prepared by Barbara Boyle Torrey and W. Ward Kingkade of the Census 
Bureau for the United Nations Seminar on Demographic and Economic Conse- 
quences and Implications of Changing Population Age Structures in Ottawa, 
September 1990. This paper was also published in the "Science Journal," March 
30, 1990, Volume 247. 

13. "Changes in Life Expectancy — 1900 to 1990," was prepared by Kevin Kin- 
sella of the Census Bureau for presentation at an International Conference on 
Aging: Nutrition and the Quality of Life in Marbella, Spain. The paper summa- 
rizes levels of and changes in life expectancy at birth and at older ages in indus- 
trialized countries during the 20th century. Trends in mortality and morbidity 
are summarized in the context of the historic epidemiological transition from 
infectious to chronic diseases. Cause-specific mortality and decomposition of life 
expectancy into active and inactive components are examined. There is also an 
initial attempt to correlate life expectancy with physical attributes that may re- 
flect differences in nutrition. 

14. "Demography of Older Populations in Developed Countries," was pub- 
lished as a chapter in the Oxford Textbook of Geriatric Medicine. Richard 
Suzman of the National Institute on Aging, Kevin Kinsella of the Census 
Bureau, and George C. Myers of Duke University are the authors. The chapter 
explores differences and similarities in the aging process and among the elderly 
populations of 34 industrialized nations. The chapter reviews past and projected 
trajectories of the growth of older populations, socioeconomic characteristics, 
and current and expected health status. 

15. "The Paradox of the Oldest Old in the United States: An International 
Comparison," was published as a chapter in "The Oldest Old," ed. by Richard 
Suzman, David Willis, and Kenneth Martin, Oxford University Press publica- 
tion, 1992. Barbara Boyle Torrey and Kevin Kinsella of the Census Bureau and 
George C. Myers of Duke University are the authors. The paper focuses on de- 
mographic trends, marital status, and living arrangements, and income, related 
to the oldest old (80 + ) in eight countries. Data are shown from 1985 to 2025. 

16. "Suicide at Older Ages — An International Enigma," was prepared by 
Kevin Kinsella of the Census Bureau for presentation at the Gerontological So- 
ciety of America Meeting, November 1991. This paper examines suicide rates in 
the United States compared with those in 20 industrialized countries. He used 
data from World Health Organization files from 1965 through 1989. 

17. A software program of the International Data Base on aging was created 
for use on microcomputers and is being distributed by the Interuniversity Con- 
sortium for Political and Social Research at the University of Michigan. 



35 



18. A wall chart on Global Aging was prepared by the CIR for wide distribu- 
tion. It is based largely on information from the International Data Base on 
Aging. The multicolored chart includes demographic and social statistics for 100 
countries. It also features tables and graphs that highlight important research 
topics in the field of aging. 

19. "A Comparative Study of the Economics of the Aged," was presented at 
the Conference on Aged Populations and the Gray Revolution in Lou vain, Bel- 
gium in 1986. Barbara Boyle Torrey and Kevin Kinsella of the Census Bureau 
and Timothy Smeeding of Vanderbilt University are the authors. The paper 
presents estimates of how social insurance programs for the elderly have grown 
as a percentage of gross domestic product in several countries partly as a result 
of lowering retirement age and an increase in real benefits. It then discusses 
how the labor force participation of the elderly in these countries has uniformly 
declined. Finally, it examines what contribution the Social Security benefit 
makes to the total income of the elderly and how the average income of the 
elderly compares with the average national income in each country. 

20. "Aging in the Third World" was published in "International Population 
Reports," Series P-95, No. 79. 

21. "An Aging World" was published in "International Population Reports," 
Series P-95, No. 78. 

B. The Census Bureau completed a contract with Meyer Zitter, a consultant in 
demographics, to work with other industrialized countries to produce international- 
ly-comparable data on the older population from the 1990 round of censuses. A 
report titled "Comparative International Statistics available on the Older Popula- 
tion" was prepared by Meyer Zitter and is available. The report focuses on data 
available from the 1980 round of censuses and what subjects will be available from 
the 1990 round of censuses. The countries also sent 1980 census tabulations that are 
somewhat comparable. This report will make it possible to recommend tabulations 
for 1990 that countries may wish to produce to allow international comparability. 

V. Other 

A. Information on the elderly population is included in the Census Bureau's publi- 
cation, "Population Profile of the United States: 1991," Current Population Reports, 
Series P-23, No. 173. 

B. The Census Bureau prepared a paper on "Emerging Data Needs for the Elderly 
Population in the 21st Century," for public discussion of the census of 2000. 

ITEM 3. DEPARTMENT OF DEFENSE 

February 22, 1993. 

Dear Mr. Chairman: The Department is pleased to have the opportunity to pro- 
vide information on our activities on behalf of older Americans. 

We have enclosed a summary of the various efforts taken by the Department in 
addressing the important issue of eldercare insofar as it relates to our personnel 
and their families. We have also included a copy of the recently published DOD El- 
dercare Handbook. 1 The Department remains committed to undertaking further ini- 
tiatives in this area. 
Sincerely, 

Robert M. Alexander, 
Lieutenant General, USAF. 

Enclosures. 

DEPARTMENT OF DEFENSE— 1992 ELDERCARE INITIATIVES 

The Office of the Assistant Secretary of Defense for Health Affairs has several 
programs relating to older Americans who have eligibility in the Military Health 
Service System, including the Military Treatment Facilities (MTFs) and the Civilian 
Health and Medical program of the Uniformed Services. Enclosed are two Fact 
Sheets on the Department of Defense initiatives with the Department of Veterans 
Affairs and the Health Care Financing Administration. These programs provide 
services to the Department's retiree population eligible for treatment on a space 
available basis in MTFs and the retiree population over 65 who are eligible for Med- 
icare. 



1 Held in Committee files. 



36 



The Office of Personnel Support, Families and Education (PS, F&E) in the Office 
of the Assistant Secretary of Defense (Force Management and Personnel) has taken 
several important steps in addressing eldercare issues and support for DOD family 
members providing care for aging persons. Recognizing the growing impact of elder- 
care issues in the workplace, the Department has developed specific resources to 
assist military and civilian personnel in dealing with this important subject. 

In 1991, DOD established an "Eldercare Task Force" with representatives from 
the Departments of Army, Navy and Air Force along with representatives from the 
Office of the Deputy Assistant Secretary of Defense, Equal Opportunity, the Chap- 
lain's Board and the Federal Women's Program. The task force met to explore ways 
to provide support for the elderly and their caregivers. Several important initiatives 
emanated from the task force's recommendations. 

A major recommendation of the task force was to develop a handbook that would 
assist DOD personnel with caretaker issues. This resource, the DOD Eldercare 
Handbook, is enclosed for your information. The handbook was developed by an el- 
dercare expert in consultation with DOD offices familiar with the unique needs of 
DOD personnel, such as long distance care. The handbook was distributed DOD-wide 
and is available for military and civilian personnel through the Family Centers, Ci- 
vilian Personnel Offices, Chaplains' offices, libraries, retired affairs offices and med- 
ical facilities. An accompanying public affairs notice announcing the publication 
and availability of the handbook was also distributed throughout the Department. 

Currently, the Department is completing the Eldercare Guide for Professionals, 
which is designed for professionals who deal with DOD personnel and their families 
who may be facing eldercare issues. The guide will enable these professionals to 
identify areas of concern and to assist individuals who deal with various aging situa- 
tions. It will also help professionals identify resources that may be helpful in ad- 
dressing the needs of the families confronted with eldercare concerns. 

The DOD Family Conference, held in November 1992, had over 500 participants 
from around the world. Participants represented family support leadership, senior 
noncommissioned officers and volunteers in family programs. The conference fea- 
tured two important plenary speakers who addressed the issues of aging and elder- 
care. Dr. Harry Sussman, a noted expert in work/family issues, presented an excel- 
lent discussion on the aging of the American population. Dr. Michael Creedon, a 
leading eldercare expert, addressed the conference on the needs, resources and 
issues of caregivers for the elderly. Both speakers went far in heightening the 
awareness of the Department's family support leaders who were at the conference. 

The Department staff is currently reviewing materials to determine which re- 
sources would be useful to personnel at the field activity level who may conduct el- 
dercare classes and workshops. The Department is obtaining some of the highly pro- 
fessional materials which have been developed in this area. 

The Military Family Clearinghouse, a component of the Office of Family Policy, 
Support and Services within PSF&E, has compiled an extensive bibliography on el- 
dercare. This bibliography covers a wide range of eldercare resources and issues. 
The Clearinghouse is a focal point of research and resources for DOD professionals 
dealing with work/family programs and issues. 

The Department has entered into a collaborative intergenerational research effort 
involving an Army officer, Major Michael Parker, who is conducting post-doctoral 
research at the University of Michigan, and Dr. Hiroko Akiyama, from the Univer- 
sity of Michigan's Institute of Social Research. The research will analyze the 1992 
Department of Defense Member and Spouse Survey data to: 

1. Identify the magnitude of military families' involvement in giving assist- 
ance to older relatives. 

2. Assess the prevalence of multiple family responsibilities such as the con- 
current child and eldercare. 

3. Identify military demographics and the needs of those who bear such re- 
sponsibilities for the purpose of designing preliminary predictive models and 
cost-effective intervention strategies. 

4. Evaluate the "life health" status of military families experiencing the ef- 
fects of being responsible for both children and elderly parents simultaneously. 

5. Gauge the impact of elder responsibilities on vocational performance and 
readiness. 

The Department of Defense is clearly aware of the long-term implications of the 
aging of the American population and is committed to ongoing efforts in support of 
this important work/family issue. 



37 



ITEM 4. DEPARTMENT OF EDUCATION 

Dear Senator Pryor: Thank you for your recent letter to Secretary Alexander in 
which you requested information on initiatives or activities taken by our Depart- 
ment on behalf of older persons and their families for Volume II of the annual 
report of the U.S. Special Committee on Aging, Developments in Aging. Your letter 
was forwarded to the Office of Vocational and Adult Education for a reply. 

Activities for older Americans and their families are provided under the Adult 
Education Act (AEA), Public Law 100-297, as amended by the National Literacy 
Act, Public Law 102-73, and implemented by the State-administered adult education 
program. Generally, the purpose of the Adult Education Act is to provide basic edu- 
cation and literacy instruction to adults who are 16 years of age and older or beyond 
the age of compulsory school attendance under State law. The Act encourages the 
establishment of programs that will enable adults to acquire the basic educational 
skills necessary for literate functioning, to benefit from job training and retraining 
and to obtain productive employment, and to continue their education to at least 
secondary level completion. 

In 1991, the total number of participants in the AEA program was 3.7 million. 
Approximately 599,947 or about 16 percent of all persons served in adult education 
programs were 45 years of age or older. Participation by persons aged 60 and over 
was 185,749. Data in the table that follows show participation by these age groups 
from 1988 to 1991. 



Program year Ages 45 to 59 Ages 60 plus Total 



1988 


338,395 


195,184 


533,579 


1989 


370,942 


171,617 


542,559 


1990 


406,405 


198,333 


604,738 


1991 


414,198 


185,749 


599,947 



The Federal adult education program addresses the needs of older adults by em- 
phasizing functional competency and grade level progression, from the lowest liter- 
acy level through attaining the General Educational Development (GED) Certificate. 
States also operate special projects to expand programs and services for older per- 
sons through individualized instruction, use of print and audio-visual media, home- 
based instruction, and curricula focused on coping with daily problems in maintain- 
ing health, managing money, using community resources, understanding govern- 
ment, and participating in civic activities. 

Equally significant are the expansion of the delivery system through satellite 
learning centers and increased public awareness through clearinghouses. These 
recent developments assist older Americans in overcoming barriers to participation. 
Where needed, supportive services, such as transportation, are provided. Self-learn- 
ing preferences are recognized and assisted through the provision of information, 
guidance, and study materials. To reach more people in the targeted age range, 
adult education programs often operate in conjunction with senior citizen centers, 
nutrition programs, nursing homes, and retirement and day care centers. 

The Federal adult education program will continue to provide support for services 
in the States to meet the learning needs of older Americans. Increased cooperation 
among organizations, institutions, and community groups involved in this area at 
the national, State, and local levels should lead to increased sharing of resources 
and expanded services. 

Please let me know if I can be of further assistance to you. 
Sincerely, 

Betsy Brand. 

ITEM 5. DEPARTMENT OF ENERGY 

December 18, 1992. 

Dear Mr. Chairman: In response to your letter of October 27, 1992, requesting an 
update of the Department's current and upcoming activities of particular interest to 
older Americans, I am submitting the following report. The document describes de- 
partmental activities of interest to senior citizens in the areas of energy efficiency 
programs, information collection and distribution, public participation, and research 
on the biological and physiological aging process. 



38 



I am pleased to contribute to your annual report of Federal activities and pro- 
grams on behalf of older Americans. 
Sincerely, 

James D. Watkins, 
Admiral, U.S. Navy (Retired). 

Enclosure. 

INTRODUCTION 

The mission of the U.S. Department of Energy (DOE) is to develop energy policies 
and programs in support of the President's broad objectives for America s future: 
sustained, noninflationary economic growth; good stewardship of the environment; 
and long-term strategic security. President Bush requested the development of a Na- 
tional Energy Strategy (NES) in 1989. As the President directed, Secretary of 
Energy James D. Watkins crafted a strategy that emphasized reliance on market 
forces to balance our increasing need for energy at reasonable prices; our commit- 
ment to a safer, healthier environment; our determination to maintain an economy 
second to none; and our goal to reduce reliance on insecure energy supplies. 

Following release of the NES in 1991, President Bush submitted to the Congress 
legislation to carry out key features of his strategy. The Energy Policy Act of 1992, 
passed by Congress and signed into law by the President on October 24, 1992, con- 
tains most of the President's original legislative proposals. In Secretary Watkins' 
view, this act is "the most comprehensive and balanced energy legislation ever en- 
acted ... it will serve to fuel new jobs, greater energy security and a cleaner envi- 
ronment." Secretary Watkins added that "The Energy Policy Act will stimulate do- 
mestic energy production, promote energy efficiency, increase competition in the 
electricity sector and reduce consumer costs, and develop alternatives to imported 
oil such as clean-burning, domestic natural gas." 

Increased conservation and energy efficiency by government, industry, and con- 
sumers are projected under the Act (based upon the assumption described in the 
1991 National Energy Strategy) to reduce the Nation's cumulative energy demand 
by the equivalent of about 8 billion barrels of oil between now and the year 2010. 
The bill is also estimated to increase the use of renewable energy by more than 20 
percent and alternative fuels by more than 50 percent over projected 2010 levels. 

The Act has the potential to reduce oil imports by about 4.7 million barrels a day 
by the year 2010. This represents a one-third cut in the projected level of petroleum 
imports. Over the next 15 years, the Act is estimated to keep about $400 billion (in 
1990 dollars) from flowing overseas for oil — a significant positive contribution to the 
U.S. balance of trade. The Act is projected to provide substantial energy cost savings 
for consumers. The Nation's electricity consumers will save about $250 billion (in 
1990 dollars) over the next 15 years — an average savings of about $750 per house- 
hold. 

"Together with the more than 90 NES initiatives which the Bush Administration 
has been able to undertake on its own, this Act will result in a cleaner, more pros- 
perous and more secure energy future for all Americans," Secretary Watkins added. 
"This legislation will create hundreds of thousands of jobs and increase our gross 
domestic product by over $500 billion." 

The following provides a brief survey of DOE programs and activities of particular 
interest to senior citizens. 

Energy Efficiency Programs 

Weatherization Assistance Program. — The elderly and the handicapped receive 
priority under this program, which provides grants to States for the installation of 
energy-saving building envelope and heating and cooling system measures in low- 
income homes. The program operates through a network of State grantees and ap- 
proximately 1,200 local subgrantee agencies. Local service providers are predomi- 
nantly community action agencies. In addition to DOE appropriations, State and 
local programs receive funding from the Health and Human Services Low Income 
Home Energy Assistance Program, from utilities, and from States. 

In 1992, the Weatherization Assistance Program awarded $188,924,996 of appro- 
priated funds in grants to the 50 States, the District of Columbia, and nine Native 
American tribal organizations for weatherization of the homes of low-income fami- 
lies. As of March 31, 1992 (the end of the most recent program year), over 4 million 
homes had been weatherized with Federal, State, and utility funds; of these, an esti- 
mated 1.7 million were occupied by elderly persons. 

State Energy Conservation Program. — The State Energy Conservation Program 
(SECP) was created to promote energy efficiency and to reduce the growth of energy 



39 



demand. Under this program, DOE provides technical and cost-shared financial as- 
sistance to States to develop and implement comprehensive plans for specific energy 
goals. At present, all States, the District of Columbia, and U.S. Territories partici- 
pate in the SECP. 

Energy Extension Service. — The Energy Extension Service (EES) was established 
as a Federal /State partnership to provide small-scale energy users with personalized 
information and technical assistance to facilitate energy efficiency and the use of 
renewable resources. The EES was repealed by Public Law 102-486, the Energy 
Policy Act of 1992. DOE is encouraging States to incorporate EES functions into a 
more broadly defined SECP. 

Senior citizens are eligible for services provided through the SECP and (until its 
recent repeal) the EES. In addition, many States have developed and implemented 
projects specifically for the elderly. Examples include senior citizen weatherization 
projects and related training, hands-on energy conservation workshops, low-interest 
loan programs, senior energy savings months, and numerous seminars addressing 
the needs of senior citizens. These projects are often cosponsored with agencies 
whose primary focus is on senior citizens. In fiscal year 1992, $16,194,000 was appro- 
priated for SECP and EES. 

Information Collection and Distribution 

The Energy Information Administration collects and publishes comprehensive 
data on energy consumption in the residential sector through the Residential 
Energy Consumption Survey (RECS) and the Residential Transportation Energy 
Consumption Survey (RTECS). The RECS includes data collected from individual 
households throughout the country, along with actual billing data from the house- 
holds' fuel suppliers for a 12-month period. The data include information on energy 
consumption, expenditures for energy, cost by fuel type, and related housing unit 
characteristics (such as size, insulation, and major energy-consuming appliances). 
The RTECS collects data on characteristics of household vehicles and annual miles 
traveled. The RECS and the RTECS contain data pertaining to the elderly. 

The results of these surveys are analyzed and published by the Energy Informa- 
tion Administration. The most recent RECS was conducted for calendar year 1990. 
Results of the 1990 RECS are published in three reports: "Housing Characteristics 
1990 (published in May 1992); Household Energy Consumption and Expenditures 
1990; and Household Energy Consumption and Expenditures 1990 Supplement: Re- 
gional Data" (both to be published in March 1993). The next RECS will be conducted 
for 1993. 

The most recent survey for which all reports have been published and the data 
file is available is the 1987 RECS. Results of the 1987 RECS are published in three 
reports. "Housing Characteristics 1987" (published May 1989); "Household Energy 
Consumption and Expenditures 1987 Part 1: National Data" (published October 
1989); and "Household Energy Consumption and Expenditures 1987 Part 2: Regional 
Data" (published January 1990). The data file for the 1987 RECS is available on dis- 
kettes for use with personal computers. The data file contains the ages of all house- 
hold members. 

"Household Energy Consumption and Expenditures 1987 Part 1: National Data" 
provides estimates of consumption and expenditures of electricity, natural gas, fuel 
oil, kerosene, and liquefied petroleum gas for elderly households. Also included in 
the report is a discussion of energy use and the elderly, which indicates that in 
1987, the elderly used about 10 percent more energy to heat their homes than the 
nonelderly, even after adjusting for weather and size of the housing unit. Overall 
energy expenditures were less for the elderly for all end uses except space heating, 
which was 13 percent higher. Approximately 61 percent of the elderly's total energy 
consumption was for space heating, and about 38 percent of their total energy ex- 
penditures were for heating. 

"Household Energy Consumption and Expenditures 1987 Part 2: Regional Data" 
provides energy consumption and expenditure data by four census regions and nine 
census divisions. These data are also presented by age of householder. 

The RTECS was conducted for calendar year 1991 and a report will be published 
late 1993. However, the most recent RTECS for which data are published was con- 
ducted during 1988. Results of this survey are published in "Household Vehicles 
Energy Consumption 1988" (published February 1990). This publication presents 
data, categorized by age of householder, on vehicle characteristics, vehicle miles 
traveled, gallons of motor vehicle fuel consumed, and expenditures for motor vehicle 
fuel. Data from the 1988 RTECS show that the elderly drove fewer miles and used 
less vehicle fuel per household than the nonelderly. Vehicle fuel consumption and 



40 



average miles traveled also differed among the elderly. Households with only one 
elderly adult spent an average of $426 per household for vehicle fuel and drove 
7,229 miles compared to two-adult households with a 60-year or older householder. 
These households drove an average of 14,058 miles and spent about $808 per house- 
hold. 

The published reports and the data diskettes for the 1987 RECS and the 1988 
RTECS can be obtained from the Superintendent of Documents, U.S. Government 
Printing Office, Washington, D.C. 20401. 

Public Participation Activities 

During fiscal year 1992, the Department of Energy continued to work with the 
National Energy and Aging Consortium, Inc., a network of more than 40 organiza- 
tions from the public and private sectors. The National Energy and Aging Consorti- 
um (NEAC) is an organization that brings Federal agencies together with national 
aging organizations and the private sector to discuss and implement solutions to the 
energy-related needs of the elderly. 

The Office of the Deputy Assistant Secretary for Consumer and Public Liaison 
represents the Department in the Consortium by serving on the Federal Advisory 
Committee to the NEAC. Through participation in this group, DOE continues to ex- 
ercise leadership in forming partnerships with a variety of organizations that have 
worked with elderly citizens to assist with their energy needs and concerns. 

During 1992, the National Energy and Aging Consortium continued to work with 
the Oklahoma Energy and Aging Consortium in a research project funded by the 
Administration on Aging which is designed to establish new State energy and aging 
consortia. Participants were drawn from eight States interested in forming State 
energy and aging consortia, including: Connecticut, Illinois, Michigan, New Mexico, 
Pennsylvania, Tennessee, Texas, and Virginia. The project's highly successful "Na- 
tional Dissemination Conference" was held January 29-31, 1992, in Washington, 
D.C. 

Throughout 1992, the Department of Energy staff maintained open channels of 
communication with Federal agencies and departments to improve information ex- 
change about energy assistance programs. This information exchange gives particu- 
lar emphasis to programs that allow for attention to the elderly. 

Research Related to Biological Aging 

In 1992, the Office of Health and Environmental Research (OHER) and the Office 
of Environment, Safety and Health administered research that used the department 
of Energy's (DOE) unique laboratory capabilities and university research facilities to 
understand basic biological principles and the health effects of radiation and 
energy-related chemicals. As part of its research program, DOE sponsors two catego- 
ries of studies (human epidemiological and animal studies) that are indirectly con- 
cerned with understanding biological changes over time and various biological proc- 
esses, including those of aging. The Department continues research to characterize 
late-appearing effects induced by chronic exposure to low levels of physical agents. 

Because health effects that are caused by chronic low-level exposure to energy- 
related toxic agents may develop over a lifetime, they must be distinguished from 
normal aging processes. To distinguish between induced and spontaneous changes, 
information on changes that occur throughout the lifespan is collected for both ex- 
perimental and control groups. These data help characterize normal aging process- 
es, as well as the toxicity of energy-related agents. Additional studies are conducted 
to obtain a better understanding of the aging process itself. As in the past, lifetime 
studies of humans and animals constitute the major research related to biological 
aging. Research concerned with the aging process has been conducted at several of 
the Department's contractor facilities. Summarized below are specific research 
projects addressing aging that the Department sponsored in 1992. 

LONG-TERM STUDIES OF HUMAN POPULATIONS 

Through the Office of Environment, Safety and Health, the DOE supports epide- 
miological studies of health effects in humans who may have been exposed to chemi- 
cals and radiation associated with energy. Information on lifespan and aging in 
human populations is obtained as part of these studies. Because long-term studies of 
human populations are difficult and expensive, they are initiated on a highly selec- 
tive basis. 

The Radiation Effects Research Foundation (RERF), sponsored jointly by the 
United States and Japan, continued work on a lifetime followup of survivors of 



41 



atomic bombings that occurred in Hiroshima and Nagasaki in 1945. Over 100,000 
persons are under observation in this study. 

An important feature of this study is the acquisition of valuable quantitative data 
on dose-response relationships. Studies specifically concerned with age-related 
changes also are conducted. No evidence of radiation-induced premature aging has 
been obtained. 

After being accidentally exposed in 1954 to radioactive fallout released during the 
atmospheric testing of a thermonuclear device, a group of some 200 inhabitants of 
the Marshall Islands has been followed clinically, along with unexposed controls, by 
medical specialists at the Brookhaven National Laboratory. Thyroid pathology, 
which has responded well to medical treatment, has been prevalent in individuals 
heavily exposed to radioiodine. 

STUDIES IN THE FORMER SOVIET UNION 

The DOE has also become involved in the studies of two major populations in the 
Former Soviet Union. The first is the population which was exposed to radiation as 
a result of the accident at the Chernobyl Nuclear Power Plant. Numerous pilot 
projects have been conducted to reconstruct dose to populations affected by the acci- 
dent, and a large-scale study of thyroid disease in children in Byelarus was recently 
initiated. The second population is those persons exposed to ionizing radiation and 
chemicals as a result of operations at a Russian nuclear weapons complex in the 
Southern Ural Mountains. Through studies of this population, we hope to learn 
more about the health effects of joint exposure to chronic low-level radiation and 
mixtures of chemicals. 

Nearly 2,000 persons exposed to radium, occupationally or for medical reasons, 
have been studied at the Center for Human Radiobiology, Argonne National Labora- 
tory. 

Other epidemiological or human studies currently involving the Department 
include: 

A Los Alamos National Laboratory epidemiologic study of plutonium workers 
at three Department of Energy facilities. An estimated 15,000 to 20,000 workers 
will be followed in this retrospective mortality study. 

A study of some 600,000 contractor employees at Department of Energy facili- 
ties who are being analyzed in an epidemiologic study to assess health effects 
produced by long-term exposure to low levels of ionizing radiation. 

The U.S. Uranium/Transuranium Registry, which is operated by Washington 
State University, is collecting occupational data (work, medical, and radiation 
exposure histories), as well as information on mortality in worker populations 
exposed to plutonium or other transuranium radioelements. 

STUDIES USING LABORATORY ANIMALS 

Although epidemiological studies of humans provide the most relevant data for 
assessing health effects of chemicals or radiation in humans, animal studies provide 
supportive data for assessing these effects. 

The DOE uses rodents in large-scale studies of the effects induced by low doses of 
ionizing radiation. Studies using rodents to determine the chronic effects of radi- 
ation are under way at the Lawrence Berkeley Laboratory and at the Oak Ridge 
National Laboratory. 

Larger, longer-living mammals (such as dogs) may represent better human surro- 
gates for chronic diseases than do shorter-lived animals. Because of this, under- 
standing the effects of energy-related agents on longer-lived animals is also impor- 
tant. Several years ago, DOE initiated several studies using dogs that were exposed 
to a variety of energy-related agents. These continue at Lovelace Inhalation Toxicol- 
ogy Research Institute and at the Pacific Northwest Laboratory; most of these stud- 
ies are coming to closure. In these final phases, emphasis is being placed on data 
analysis and on pursuing new and creative methods of statistical analyses. This re- 
search should increase knowledge of lifespan, age-related changes, morbidity, mor- 
tality, and causes of death, as well as alterations in these characteristics that may 
be induced by radiation. Because of changes in its research goals and directions 
during the last few years, no additional studies in dogs have been initiated by DOE. 

RESEARCH CONCERNED WITH AGING 

Interest in biological aging has continued in several of the DOE laboratories and 
has resulted in additional research at the molecular, cellular, and organismal levels 
of biological organization. Examples include: (a) research at the Lovelace Inhalation 
Toxicology Research Institute on effects of age on lung functions and structure of 



42 



adult animals and (b) the study and diagnosis via radiopharmaceuticals and new im- 
aging devices of age-related dysfunctions of the brain and heart, including senile de- 
mentia, Alzheimer's disease, stroke, and atherosclerosis, 

Radiobiology Archives Used to Investigate Alzheimer's Disease. — Researchers from 
the University of California, Davis Medical Center are using beagle brain tissue 
stored in the National Radiobiology Archives at the Pacific Northwest Laboratory to 
study Alzheimer's disease. The dog is the first practical animal model observed to 
exhibit the senile amyloid plaques and tangles associated with Alzheimer's. The re- 
search is examining the correlation between clinically observed senility and patholo- 
gy. Tissues and clinical records in the archives represent a unique resource for these 
investigations. It contains a large number of aged animals along with their full med- 
ical, genetic, and life histories. Although the incidence of Alzheimer's in humans is 
approximately 30 percent at age 85, 15 percent at 75, and 10 percent at 65, prelimi- 
nary results indicate that the incidence of senile plaques in archived beagle tissues 
is nearly 50 percent at age 15. 

Alzheimer's disease has been recognized and investigated in humans since the end 
of the last century. The lack of progress in treating the disease has been due pri- 
marily to the absence of a suitable model. These archival investigations could repre- 
sent a first step toward identifying such a model. The archived tissues are especially 
valuable because several genetic and environmental factors that have been shown to 
be associated with Alzheimer's disease in humans have been carefully controlled in 
these dogs; including heredity, diet, and exposure to toxic agents. Initial investiga- 
tions have been productive — an estimate of incidence is being derived and evidence 
of an increased risk in female beagles is being explored. Current studies include 
noninvasive testing of aged beagles, from DOE life span studies, for symptoms of 
Alzheimer's senility (e.g., olfactory loss, memory loss, and EEG changes). 

TRENDS AND PROSPECTS 

Given the need to assess long-term and late-appearing effects of chemicals and ra- 
diation associated with energy, lifetime studies of animal and human epidemiologi- 
cal studies will continue. Because there is a critical need for better methods to pre- 
dict effects of exposure to low levels of chemicals and radiation, DOE research into 
these areas is receiving ever-greater emphasis. The DOE research in areas of basic 
biological principles, gene sequencing, and structural biology should eventually lead 
to better understandings of such effects. 

Although lifetime studies involving short-lived species will continue, no new life- 
time studies involving long-lived mammals are planned. Research to understand mo- 
lecular and cellular mechanisms, including aging, will continue, as will studies to 
sequence the human genome. As a result, additional information on age-related 
changes in both animals and humans should be produced. 

ITEM 6. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

January 11, 1993. 

Dear Mr. Chairman: On behalf of Secretary Sullivan, I am submitting the De- 
partment of Health and Human Services' annual report for 1992 summarizing the 
Department's activities on behalf of older Americans. We are pleased that we could 
be of assistance in developing this material for inclusion in Volume II of the Com- 
mittee's annual report, Developments in Aging. 

I hope the enclosed information will be of value to the Committee. Should your 
staff need further assistance, the point of contact on my staff is Barbara Clark on 
690-6311. 

Sincerely, 

Steven B. Kelmar, 
Assistant Secretary for Legislation. 

Enclosures. 

HEALTH CARE FINANCING ADMINISTRATION 
Long-Term Care 

The mission of the Health Care Financing Administration (HCFA) is to promote 
the timely delivery of appropriate, quality health care to its beneficiaries — approxi- 
mately 50 million aged, disabled, and poor Americans. 

Medicaid and Medicare are the principal sources of funding for long term care in 
the United States. The primary types of care reimbursed by these programs of 



43 



HCFA are skilled nursing facilities (SNFs), intermediate care facilities (ICFs), and 
home health services. 

HCFA's Office of Research and Demonstrations (ORD) conducts research studies 
on a broad variety of issues relating to long term services and their users, providers, 
costs, and quality. ORD also conducts demonstration projects that demonstrate and 
evaluate optional reimbursement, coverage, eligibility, delivery mechanisms, and 
management alternatives to the present Medicaid and Medicare programs. 

RESEARCH ACTIVITIES 

Long term care research activities in ORD can be classified according to the fol- 
lowing objectives: 

Assessing and evaluating long term care programs in terms of costs, effective- 
ness, and quality; 

Examining the effect of the hospital prospective payment system (PPS) on 
long term care providers; 

Examining alternative payment systems for long term care; and 
Supporting data development and analyses. 
Because of interest in promoting noninstitutional care, and recent increase in 
the utilization of these services, ORD's research is examining the cost, quality, 
and effectiveness of the services in the home setting. These efforts include com- 
parison of the quality, case mix, and cost of noninstitutional services, as well as 
the examination of home care provided under different payment arrangements, 
e.g., fee-for-service versus capitation. As part of these efforts, some studies are 
developing groupings of patients in both institutional and noninstitutional set- 
tings that have similar expected outcomes. Such groupings are essential since 
home health care serves so many different types of patients, some of whom may 
fully recover and some who, even under the best of circumstances, are still ex- 
pected to continue to decline. 
A major responsibility of ORD is assessing the effects of various Medicare and 
Medicaid programs and policies affects subacute and long term care services. Since 
the implementation of PPS for paying hospitals, ORD has been assessing the effects 
of this change on other parts of the health care system. Included in this research is 
the examination of the effects of the prospective payment system (PPS) on long 
term care case mix, utilization, costs, and quality. Changes in the supply of long 
term care providers are also being studied. Major research projects are underway to 
analyze the appropriateness of post-hospital care and the course and outcomes of 
that care. In recent years, there has been increased emphasis on examining episodes 
of care rather than utilization of just one type of service. Medicare files, which link 
hospital with post-hospital care, continue to be analyzed to provide information on 
trends in the post acute care utilization of post-hospital care since the passage of the 
PPS legislation. 

Several research studies by ORD are examining the course and outcomes of post- 
hospital care. After the implementation of PPS, there was increased interest in the 
post-acute care area because the resulting shorter average hospital stays were ex- 
pected to increase patients' post-acute care utilization. In addition, another purpose 
of funding this research was to gather information about decision-making at the 
point of hospital discharge and the types of patients who are referred to the various 
post-acute modalities of care. These research studies involve collection and analysis 
of data in order to provide Medicare payment, quality assurance, and coverage 
policy recommendations relating to subacute care (e.g., home health care, nursing 
homes, and rehabilitation hospitals). 

Efforts are also underway to improve the data bases, statistics, and baseline infor- 
mation upon which future assessment of needs, problem identification, and policy 
decisions will be based. 

DEMONSTRATION ACTIVITIES 

Demonstration activities in ORD include the development, testing, and evaluation 
of: 

Alternative methods of service delivery for post-acute and long term care; 

Alternative payment systems for post-acute and long term care services; and 

Innovative quality assurance systems and methods. 
In 1992, HCFA continued the operation of a major demonstration testing the ef- 
fectiveness of community-based and in-home services for victims of Alzheimer's dis- 
ease and other dementias. This project focuses on the coordination and management 
of an appropriate mix of health and social services directed at the individual needs 
of these patients and their families. In 1992, HCFA- also continued operation of a 



44 



major demonstration aimed at testing prospective payment for Medicare home 
health agencies. This program is being conducted in two phases. The first phase in- 
volves testing of prospectively established per-visit payment rates for Medicare cov- 
ered home health visits. A second phase, scheduled to begin in late 1993, will test 
per-episode payment rates for an entire episode of Medicare covered home health 
services. Substantial effort also was devoted to the design and development of a 
multi-State demonstration program to testing innovative case-mix payment and 
quality assurance methods for nursing homes that participate in Medicare and Med- 
icaid. This project is scheduled to begin by the summer of 1993. 

ORD also continued work on several other major initiatives to test innovative re- 
imbursement strategies to promote cost containment and foster quality of care. ORD 
has devoted extensive effort to the testing of capitated payment systems for a combi- 
nation of acute and long term care services, including conducting and evaluating 
the demonstration of Social /Health Maintenance Organizations (S/HMOs) and con- 
ducting the Program for All-inclusive Care for the Elderly (PACE). The purpose of 
the PACE demonstration has the purpose of replicating a unique model of managed 
care service delivery for very frail community dwelling elderly, most of whom are 
dually eligible for Medicare and Medicaid coverage and all of whom are assessed as 
being eligible for nursing home placement according to the standards established by 
participating States. Work is continuing to develop a "second generation" model of 
the S/HMO that can be tested in a future demonstration. HCFA also awarded con- 
tracts to four community nursing organizations (CNOs) in 1992. This demonstration 
will test the feasibility and effect on patient care of a capitated, nurse-directed serv- 
ice delivery system. The CNO sites are in a 1-year developmental period during 
which they are establishing detailed operating plans and protocols. At the end of 
this year, if the developmental period has proceeded as scheduled, HCFA will then 
enter into an agreement with the CNOs to begin a 3-year operational period as CNO 
sites. 

Information follows on specific HCFA research and demonstrations. 

Developing the Design for a Demonstration of Medicare Payment for Community 
Nursing Organizations 
Period: August 1988-January 1993. 
Total Funding: $326,409. 

Awardee: Project HOPE Research Center, Two Wisconsin Circle, Suite 500, Chevy 
Chase, MD 20815. 
Investigator: Robyn Stone, Ph.D. 

The purpose of this project is to assist the Health Care Financing Administration 
in designing a demonstration project (consisting of at least four sites) to provide pay- 
ment to community nursing organizations (CNOs) for home health services, durable 
medical equipment, and certain ambulatory care furnished to Medicare benefici- 
aries on a prepaid, capitated basis. Public Law 100-203 specifies that two different 
capitated payment methods must be implemented in the demonstration. Before the 
implementation of the demonstration, detailed planning and development of the 
project design elements required by the congressional mandate must be undertaken. 
These include: 

— Establishing organizational requirements and standards for CNOs. 
— Developing a detailed methodology for computing payment rates. 
— Preparing an implementation plan for the demonstration which includes devel- 
oping site selection criteria, quality assurance mechanisms, and marketing 
strategies appropriate for these sites; criteria for evaluating site proposals; se- 
lecting demonstration sites; and preparing an evaluation strategy. 
The basic elements of the demonstration design have been completed. A Request 
for Proposal to develop demonstration sites was issued in September 1991, and con- 
tracts to the project sites were awarded in September 1992. 

Community Nursing Organization Demonstration 
Period: September 1992-August 1993. 
Contractors: See Below. 

Section 4079 of Public Law 100-203 directs the Secretary to conduct demonstra- 
tion projects at four or more sites testing payment under the Medicare program for 
services furnished to Medicare beneficiaries by Community Nursing Organizations 
(CNOs). The demonstration will test the feasibility and effect on patient care of a 
capitated, nurse-directed service delivery model. Urban and rural sites as well as 
different kinds of organizations (such as home health agencies, health maintenance 
organizations) will participate. The model will cover a Medicare service package 
that includes home health care, durable medical equipment, and certain ambulatory 
care. The CNO sites may also provide other optional community services to enroll- 



45 



ees. Awardees will have a 1-year developmental period to establish detailed operat- 
ing plans and protocols. At the end of this year, if the developmental period has 
proceeded as scheduled, HCFA will then enter into an agreement with the individ- 
ual organizations to begin a 3-year operational period as CNO sites. 

Contractors 

Carle Clinic Association, 602 West University Ave., Urbana, IL 61801. 

Carondelet Health Services, Inc., Carondelet St. Mary's Hospital, 350 North Wil- 
mont Road, Tucson, AZ 85711. 

Living at Home/Block Nurse Program /Metropolitan Visiting Nurse Association, 
Ivy League Place, Suite 225, 475 Cleveland Ave. North, St. Paul, MN 55104. 

Visiting Nurse Service of New York, 107 East 70th St., New York, NY 10021- 
5087. 

Four sites were awarded contracts on September 30, 1992. These sites are located 
in Tucson, AZ, Urbana, IL, St. Paul, MN and New York, NY. A 2-day start-up meet- 
ing was held in Baltimore with Project Officers for both the Demonstration and 
Evaluation contracts, representatives from the four sites, and the evaluation con- 
tractor, Abt Associates Inc. The evaluation contractor will be active in providing 
training and technical assistance to the sites during the start-up year. 

Evaluation of the Community Nursing Organizations Demonstration 
Period: September 1992-September 1993. 
Funding: $262,433. 

Contractor: Abt Associates Inc., 55 Wheeler St., Cambridge, MA 02138-1168. 
Investigator: Robert Schmitz, Ph.D. 

Section 4079 of P.L. 100-203 directs the Secretary to conduct demonstration 
projects at four or more sites testing payment under the Medicaid program for serv- 
ices furnished to Medicare beneficiaries by Community Nursing Organizations 
(CNOs). The demonstration will test the feasibility and effect on patient care of a 
capitated, nurse-directed service delivery model. Urban and rural sites, as well as 
different kinds of sponsoring organizations (such as home health agencies, health 
maintenance organizations) will participate. The model will cover a Medicare serv- 
ice package that includes home health care, durable medicare equipment and cer- 
tain ambulatory care services. The CNO sites may also provide other optional com- 
munity services to enrollees. Sites will have a 1-year developmental period to estab- 
lish detailed operating plans and protocols. At the end of the developmental year, if 
development has proceeded as scheduled, HCFA will then enter into an agreement 
with the organizations to begin a 3-year operational period as CNO sites. 

The evaluation of the CNO demonstration is a two-tiered study. The first tier will 
focus on operational feasibility of the CNO model, relying primarily on process anal- 
yses and case studies. The evaluator will also develop an evaluation strategy for a 
possible second tier study to evaluate patient-level impacts on such measures as 
mortality, hospitalization, physician visits, nursing home admissions, and Medicare 
expenditures. The second tier evaluation will only be carried out if the number of 
sites and CNO enrollees is sufficient to evaluate patient-level impacts. 

This contract was awarded in September 1992 and is in the early developmental 
phase. 

Social Health Maintenance Organization Project for Long-Term Care 
Period: August 1984-December 1995. 
Grantees: See Below. 

In accordance with Section 2355 of Public Law 98-369, this project was developed 
and is currently implementing the concept of a social health maintenance organiza- 
tion (S/HMO) for acute and long-term care. A S/HMO integrates health and social 
services under the direct financial management of the provider of services. All serv- 
ices are provided by or through the S/HMO at a fixed annual prepaid capitation 
sum. Four sites have been selected to participate in this project. 

Of the four S/HMO demonstration sites selected, two are HMOs that have added 
long-term care services to their existing service packages and two are long-term care 
providers that have added acute care service packages. The demonstration sites uti- 
lize Medicare and Medicaid waivers, and all initiated service delivery by March 
1985. During the first 30 months of operation, Federal and State governments 
shared financial risk with the sites. This risk sharing ended August 31, 1987. This 
demonstration was extended twice by legislation. The current legislation (Public 
Law 101-508) extends the demonstration period through December 31, 1995. The S/ 
HMO sites are: 



46 



Elderplan, Inc. 

Grantee: Elderplan, Inc., 6323 Seventh Avenue, Brooklyn, NY 11220. 
Seniors Plus 

Grantee: Group Health, Inc., and Ebenezer Society, 2829 University Avenue, SE, 
Minneapolis, MN 55414. 

Medicare Plus II 

Grantee: Kaiser-Permanente Center for Health Research, 4610 Southeast Belmont 
Street, Portland, OR 97215-1795. 

SCAN Health Plan 

Grantee: Senior Care Action Network, 521 East Fourth Street, Long Beach, CA 
90802. 

Evaluation of Social Health Maintenance Organization 
Period: September 1985-July 1991. 
Total Funding: $3,533,396. 

Contractor: Institute for Health and Aging, University of California, San Francis- 
co, 201 Filbert Street, San Francisco, CA 94133. 
Investigator: Robert Newcomer, Ph.D. 

The social health maintenance organization (S/HMO) seeks to enroll, voluntarily, 
persons 65 years of age or over in an innovative prepaid program that integrates 
medical, social, and long-term care delivery systems. The S/HMO merges the health 
maintenance organization concepts of capitation financing and provider risk sharing 
developed by the Health Care Financing Administration under its Medicare capita- 
tion and competition demonstrations with the case management and support serv- 
ices concepts underlying the long-term care demonstrations serving the chronically 
ill aged, which are sponsored by the Department of Health and Human Services. 

An interim report was forwarded to Congress in August 1988. A copy of the 
report, Evaluation of the Social/Health Maintenance Organization Demonstration, 
may be obtained from the National Technical Information Service (NTIS), accession 
number PB89-2 15446. The evaluation and data collection plan for the demonstra- 
tion is available from NTIS as a technical appendix and may be obtained by using 
accession number PB89-191779. The data collection phase has been completed. Data 
analysis will be completed in winter 1993. Preliminary findings regarding health 
status, service utilization and service expenditures were presented at the Associa- 
tion for Health Services Research annual meeting. The results of this evaluation 
will provide the basis for the second interim report due to Congress by March 1993 
as mandated by Public Laws 100-203 and 101-508. 

Suitability of Grade of Membership Techniques to Correct for Selection Bias in the 
Social Health Maintenance Organization Evaluation 
Period: March 1991-June 1991. 
Total Funding: $2,500. 

Awardee: Division of Health Services Research and Policy, School of Public 
Health, University of Minnesota, 420 Delaware Street, SW., Box 729, Minneapolis, 
MN 55455. 

Investigator: Roger Feldman, Ph.D. 

The purpose of this project is to provide technical advice in assessing the suitabil- 
ity of grade of membership (GoM) analysis to correct for selection bias in the social 
health maintenance organization demonstration evaluation. 

This project has been completed. A final report entitled "Suitability of Grade of 
Membership Techniques to Correct for Selection Bias in the Social Health Mainte- 
nance Organization Evaluation" is available from the National Technical Informa- 
tion Service, accession number PB92-18552. The researchers concluded that al- 
though GoM is an innovative and useful method of data reduction, it does not cor- 
rect for selection bias in the S/HMO evaluation analyses. They further recommend 
that the effects of selection bias be tested for and, if feasible, corrected in the eval- 
uation analyses. 

Design of the Second Generation Social Health Maintenance Organization 
Period: July 1991-February 1992. 
Total Funding: $285,660. 

Awardee: Brandeis University Research Center, 415 South St., Waltham, MA 
02254. 

Investigator: Stuart Altman, Ph.D. 



47 



Section 4207(b)(4) of Public Law 101-508 requires approval of not more than four 
additional social health maintenance organization (S/HMO) sites. The purpose of 
these second generation S/HMO sites is to refine the targeting and financing meth- 
odologies and benefit design of a S/HMO. For this study, researchers are to analyze 
design issues (including recommendations) associated with the development of one 
or more models of the second generation S/HMOs. 

A draft final report has been received and is under review. 

Study of the Second Generation Social Health Maintenance Organization 
Period: July 1991-September 1992. 
Total Funding: $100,000. 

Awardee: University of Minnesota Research Center, 1919 University Ave., St. 
Paul, MN 55104. 
Investigator: Michael Finch, Ph.D. 

In accordance with Section 2355 of Public Law 98-369, the concept of a social 
health maintenance organization (S/HMO) for acute and long-term care is being im- 
plemented. The purpose of this project is to conduct an analysis of the conditions 
and considerations related to participation in a S/HMO by providers, insurers, con- 
sumers, and State Medicaid agencies. 

The final report has been accepted and is being sent to the National Technical 
Information Service. After reviewing the incentives faced by the S/HMOs and dis- 
cussing lessons learned from the first 5 years of operation, the report makes recom- 
mendations for the second generation S/HMO demonstration sites. The recommen- 
dations cover pricing and content of the chronic care benefit, provision of geriatric 
care and case management, characteristics of potential provider organizations, and 
issues to be faced in the evaluation of the second generation sites. 

Analysis of Implementation Issues Related to a Capitated Acute and Long-Term Care 
Service Delivery System 
Period: August 1991-January 1993. 
Total Funding: $99,822. 

Awardee: Brandeis University Research Center, 415 South St., Waltham, MA 
02254. 

Investigator: Walter Leutz, Ph.D. 

The purpose of this project is to analyze issues related to marketing strategies, 
reimbursement rates and mechanisms, site selection criteria, and site operational 
protocols for a capitated acute and long-term care service delivery system. 

A draft report is under review. 

Analysis of S/HMO Data to Support Research Regarding HMOs, TEFRA HMOs, and 
Long-Term Care Issues 
Period: August 1992-November 1992. 
Total Funding: $24,963. 

Contractor: Division of Health Services Research, University of Minnesota, 420 
Delaware St., SE, Box 729, Minneapolis, MN 55455. 
Investigator: Bryan Dowd, Ph.D. 

The purpose of this project is to analyze the social health maintenance organiza- 
tion (S/HMO) data to determine the capacity to support research regarding (1) HMO 
issues (e.g., cost-effectiveness of coordinated care relative to the fee-for-service (FFS) 
system, differences in access to and use of various services such as use of expensive 
technologies and provision of preventive services in HMOs relative to the FFS 
system); (2) TEFRA HMO issues (e.g., what is the effect of the phenomenon of 
"aging in place?"); and (3) long-term care issues (e.g., how does provision of expand- 
ed chronic care services influence acute care service use?). A draft final report is 
under review. 

Study of Post-Acute Care in Health Maintenance Organizations: Implications for 
Bundling 
Period: August 1991-July 1992. 
Total Funding: $83,577. 

Awardee: The RAND Policy Research Center, 1700 Main St., Santa Monica, CA 
90406. 

Investigator: Peter Jacobson, Ph.D. 

Post-acute services paid for by Medicare are typically reimbursed on a cost basis. 
Because of the success of prospective payment in restraining hospital costs with 
little attendant loss in quality of care, consideration is being given to extending this 
type of payment system to post-acute care. The innovative post-acute care programs 
developed by many Health Maintenance Organizations (HMOs) provide a natural 



48 



experiment for evaluating the feasibility of introducing a prospective payment 
structure to the present system. The purpose of this project was to determine if the 
post-acute care innovations now being implemented in HMOs can be replicated in 
the traditional fee-for-service sector. 

RAND selected six HMOs and conducted case studies of these organizations. Two 
plans were large multi-specialty group models; one plan was a medium size multi- 
specialty group HMO; one plan was a manager of health care rather than a provid- 
er; another HMO was a small staff model; and the other plan was a small group 
HMO. Two Social HMOs were included in the study. Each plan in the sample had 
over 10 years of operational experience. 

Four common issues emerged from RAND's survey of HMO post-acute care initia- 
tives: 

— HMOs are confronted with the decision of whether to provide services them- 
selves or to purchase them from a vendor; 

— Coordination of services is a critical factor in achieving effective and efficient 
care management; 

— Nonmedical services must be considered an important part of the service pack- 
age; and 

— Appropriate services must be provided in a cost effective way. 

From this study, RAND concluded that bundling hospital and post-acute care is a 
major step in the evolution of managed care. To do this successfully, there must be 
a realistic incentive structure to discourage inpatient care. There should also be con- 
tinuous patient monitoring and a coordinated transition between the different levels 
of care. In addition, medical and nonmedical services must be combined in the post- 
acute care package. Another important component in a bundling model is patient 
choice. The project's final report will be sent to the National Technical Information 
Service. 

Bundling of Acute and Post-Acute Care Services into Payment for an Episode of Care 
Period: August 1990-September 1992. 
Funding: $71,605. 

Awardee: University of Minnesota Research Center, 1919 University Ave., St. 
Paul, MN 55104. 
Investigator: Robert Kane, M.D. 

The Health Care Financing Administration (HCFA) is interested in developing al- 
ternatives to the present fee for service payment system for post-acute care. One 
approach to reconfigure this cost based reimbursement is to combine or bundle hos- 
pital and post-hospital services for Medicare beneficiaries into a single episode of 
care. This would eliminate the separate payment structure that now exists for post- 
acute services. At HCFA's request the University of Minnesota is preparing a report 
on the issue of paying for hospital and post-hospital care collectively. Various design 
options for managing, coordinating, and paying for acute and post-acute care will be 
discussed. 

The University of Minnesota's draft report was reviewed by a technical expert 
panel representing the constituencies who would be most affected by bundling 
health care services; i.e., hospitals, post-acute care providers, and consumers. A final 
report reflecting the comments and recommendations of this panel was accepted in 
December 1992 and is being submitted to the National Technical Information Serv- 
ice. 

Focused Analysis of Post-Acute Care Use for Selected Diagnosis-Related Groups 
Period: September 1991-January 1993. 
Total Funding: $130,006. 

Awardee: Brandeis University Research Center, 415 South St., Waltham, MA 
02254. 

Investigator: James Lee, Ph.D. 

For several years the Health Care Financing Administration (HCFA) has been in- 
terested in the concept of integrating post-acute care (PAC) into Medicare's prospec- 
tive payment system. This study evaluated the distributional and risk consequences 
of various alternatives for bundling and paying for PAC services on a diagnosis-re- 
lated group (DRG) type fixed-fee basis. The characteristics of patients, their vari- 
ations in types of and costs for PAC use, their probability of being rehospitalized, 
and the potential effects of different outlier policies in a bundled payment system 
were examined. Medicare claims data and the Center for Health Economics Re- 
search Multistate Data were used in the analysis. Fourteen DRGs were selected for 
study based on their homogeneity and their potential for constructing a prototypical 
bundled payment system. Oxygen and other durable medical equipment were in- 
cluded in the definition of PAC services because they were considered important 



49 



complements to home health care. The study's analytical data file was used to de- 
scribe or profile patterns in PAC use and to simulate and interpret the distribution- 
al impacts of packaged payments. 

A draft final report is currently under review. Information from this study could 
assist HCFA in exploring possible designs of alternative payment models for hospi- 
tal and post-hospital services. The final report will be available in March 1993. 

Natural History of Post-Acute Care for Medicare Patients 
Period: December 1986-December 1992. 
Total Funding: $3,702,330. 

Awardee: University of Minnesota, School of Public Health, Post-Acute Care 
Project, 704 Washington Ave., SE, Suite 203, Minneapolis, MN 55414. 
Investigator: Robert Kane, M.D. 

This is a study of the course and outcomes of post-acute care. It has two major 
components — an analysis of Medicare data to assess differences in patterns of care 
across the country and to determine the extent of substitution where various forms 
of post-acute care services are more or less available and a detailed examination of 
clinical cases from the most common diagnostic-related groupings receiving post- 
acute care in a few selected locations. Measures of the complexity of the clinical 
cases will be developed using a modification of the medical illness severity grouping 
system. This project is jointly funded by the Health Care Financing Administration 
and the Office of the Assistant Secretary for Planning and Evaluation. The condi- 
tions specifically being examined in the clinical analyses are stroke, chronic obstruc- 
tive pulmonary disease, congestive heart failure, hip fracture, and hip replacement. 
The three locations from which patients were obtained for the case studies are 
Houston, Minneapolis/St. Paul, and Pittsburgh. Patients and caregivers were fol- 
lowed with interviews 6 weeks, 6 months, and 1 year after hospital discharge, 
whether the patients were discharged to nursing homes, rehabilitation hospitals, or 
home. The results of direct observation of selected aspects of patients' functional 
ability over time were also recorded. The study will provide extensive clinical and 
functional information about the kinds of patients who receive post-acute care and 
what happens to them. 

The awardee has submitted a draft interim report of preliminary outcome results. 
The final report, which is expected in winter 1993, will include cost comparisons. 

New Jersey Respite Care Pilot Project 
Period: July 1988-September 1992. 

Awardee: New Jersey Department of Human Services, 5 Quakerbridge Plaza, CN 
712, Trenton, NJ 08625. 
Investigator: William Ditto. 

The New Jersey Respite Care Pilot Project was established to provide the kind of 
support and assistance that caregivers of the frail elderly and functionally impaired 
need to continue in that capacity. It was developed to learn if respite care services 
enhance and sustain the role of the family as caregivers by relieving them of some 
of their custodial responsibility, and whether these services delay or avert institu- 
tionalization. The project was designed to measure the impact on both care recipi- 
ents and their caregivers. 

Respite care is provided under this program by using short-term and intermittent 
companion services: homemaker, home health aide, and personal care services; 
adult day care, both social and medical; and out-of-home respite in a nursing home 
or residential care facility. In addition to these services, peer support, training, and 
counseling are being provided to family members. All of the services are available 
in either planned or emergency situations. 

Federal funding of this statewide project began on July 1, 1988, and was originally 
scheduled to end on September 30, 1990. However, the project was extended until 
September 30, 1992 by the Omnibus Budget Reconciliation Act of 1990. During this 
study respite services have been provided to over 7,900 caregivers. 

Preliminary data indicate that the typical caregiver is a 64-year-old female. About 
40 percent of the caregivers are spouses of the care recipient and another 40 percent 
are their children. More than 80 percent assist with dressing and bathing and over 
60 percent help with toileting. Caregivers report that the lack of time for them- 
selves, coupled with the related stress, are the most overwhelming aspects of provid- 
ing care. A substantial number also find the physical aspects of caregiving particu- 
larly difficult. 

Homemaker/ home health aide services have been provided to almost 80 percent 
of the care recipients. Fourteen percent of the recipients have used day care pro- 
grams and 17 percent have had overnight stays in nursing homes or residential care 
facilities. Older care recipients have been less likely to use out-of-home services. 



50 



The median age of the care recipient is 79 and only 9 percent are age 60 or under. 
The large majority of this group's medical problems appear age-related. Twenty-two 
percent of the care recipients have Alzheimer's disease or a related disorder. The 
evaluation of the project is being conducted by the Institute for Health, Health Care 
Policy, and Aging Research at Rutgers University. A final report is expected in 
March 1993. 

Program for All-inclusive Care for the Elderly (On Lok) Case Study 

Period: August 1989-June 1991. 
" Total Funding: $172,138. 

Awardee: University of Minnesota Research Center, 1919 University Ave., St. 
Paul, MN 55104. 

Investigator: Robert Kane, M.D. 

For this study, researchers will provide a descriptive analysis of the early stages 
of the Program for All-Inclusive Care for the Elderly (PACE) demonstration. They 
will examine in detail the model of service delivery provided by On Lok Senior 
Health Services, San Francisco, California, and the degree to which aspects of this 
model are successfully replicated in eight sites nationwide. The results are expected 
to have utility as subsequent sites are developed for later implementation. 

Two rounds of site visits to On Lok and PACE sites were completed and an inter- 
im report was submitted. A final report entitled Qualitative Analysis of the Pro- 
gram for All-Inclusive Care for the Elderly (On Lok) Case Study has been sent to 
the National Technical Information Service, accession number PB92-1784091. In ad- 
dition to comparing eight PACE sites to On Lok on seven features of the PACE 
model, the researchers offer some lessons learned from the first eight sites regard- 
ing replicability; sources of start-up and development funds, census building, staff- 
ing, and patient mix of enrollees are seen as critical issues to future sites. Also of- 
fered are some issues to be faced by the evaluators, including the difficulty of select- 
ing appropriate comparison groups, data equivalence across experimental and com- 
parison groups, the need to collect additional data regarding enrollee outcomes (e.g., 
client and family satisfaction, affect, and quality of life), and statistical power and 
the role of pooling. 

The following article has been published: 

— Kane, R., Hixon Illston, L., and Miller, N.: Qualitative Analysis of the Program 
of All-inclusive Care for the Elderly (PACE). "The Gerontologist," forthcoming. 

Quality of Care in the Program for All-inclusive Care for the Elderly Model 
Period: August 1991-July 1992. 
Total Funding: $60,117. 

Awardee: University of Minnesota Research Center, 1919 University Ave., St. 
Paul, MN 55104. 
Investigator: Robert Kane, M.D. 

The purpose of this study is to develop measures to assess quality of care on both 
a routine and periodic basis in the Program for All-inclusive Care for the Elderly 
(PACE) model of care. These measures may be used in PACE site quality assurance 
programs and quality assurance monitoring undertaken by the Health Care Financ- 
ing Administration and State Medicaid agencies. Attention will be given to meas- 
ures that reflect concerns relevant to both acute and long-term care and the provi- 
sion of that care in an integrated, capitated system. 

A series of meetings has been held with PACE site clinicians and experts in geri- 
atric care to develop tracer conditions for the quality assurance program. Prelimi- 
nary findings were presented to the PACE Public Policy Forum in May 1992. A 
final report was received in November 1992 and is being submitted to the National 
Technical Information Service. 

Frail Elderly Demonstration: The Program for All-inclusive Care for the Elderly 
Period: June 1990-April 1995. 
Grantees: See Below. 

As mandated by Public Law 99-509, as amended, the Health Care Financing Ad- 
ministration will conduct a demonstration which replicates, in not more than 15 
sites, the model of care developed by On Lok Senior Health Services in San Francis- 
co, California. The Program for All-Inclusive Care for the Elderly (PACE) demon- 
stration replicates a unique model of managed-care service delivery for 300 very 
frail community-dwelling elderly, most of whom are dually eligible for Medicare and 
Medicaid coverage and all of whom are assessed as being eligible for nursing home 
placement according to the standards established by participating States. The model 
of care includes as core services the provision of adult day health care and multidis- 
ciplinary case management through which access to and allocation of all health and 



51 



long-term care services are arranged. Physician, therapeutic, ancillary, and social 
support services are provided on site at the adult day health center whenever possi- 
ble. Hospital, nursing home, home health, and other specialized services are provid- 
ed extramurally. Transportation is also provided to all enrolled members who re- 
quire it. This model is financed through prospective capitation of both Medicare and 
Medicaid payments to the provider. Demonstration sites are to assume financial risk 
progressively over 3 years, as stipulated in the Omnibus Budget Reconciliation Act 
of 1987. The eight sites and their State Medicaid agencies that have been granted 
waiver approval to provide services are: 

Elder Service Plan . 

Period: October 1989-May 1993. 

Grantee: East Boston Geriatric Services, Inc., 10 Gove St., East Boston, MA 02128. 
Period: October 1989-May 1993. 

Grantee: Massachusetts State Department of Public Welfare, 180 Tremont St., 
Boston, MA 02111. 

Providence ElderPlace 

Period: October 1989-May 1993. 

Grantee: Providence Medical Center, 4805 Northeast Glisan St., Portland, OR 
97213 

Period: October 1989-May 1993. 

Grantee: Oregon State Department of Human Resources, 313 Public Service 
Building, Salem, OR 97310. 

Comprehensive Care Management 
Period: October 1989-August 1993. 

Grantee: Beth Abraham Hospital, 612 Allerton Ave., Bronx, NY 10467. 
Period: October 1989-August 1993. 

Grantee: New York State Department of Social Services, 40 North Pearl St., 
Albany, NY 12243. 

Palmetto SeniorCare 

Period: August 1990-September 1993. 

Grantee: Richland Memorial Hospital, Five Richland Medical Park, Columbia, SC 
29203. 

Period: August 1990-September 1993. 

Grantee: South Carolina State Health and Human Services Finance Commission, 
P.O. Box 8206, Columbia, SC 29202. ' 

Community Care for the Elderly 
Period: August 1990-October 1993. 

Grantee: Community Care Organization of Milwaukee County, Inc., 1845 North 
Farwell Ave., Milwaukee, WI 53202. 
Period: August 1990-October 1993. 

Grantee: Wisconsin State Department of Health and Social Services, P.O. Box 
7850, Madison, WI 53707. 

Total Longterm Care, Inc. 
Period: August 1991-July 1994. 

Grantee: Total Longterm Care, Inc., 1801 East 19th Ave., Denver, CO 80218. 
Period: August 1991-July 1994. 

Grantee: Colorado Department of Social Services, 1575 Sherman St., Denver, CO 
80203. 

Bienvivir Senior Health Services 

Period: December 1991-January 1995. 

Grantee: Bienvivir Senior Health Services, 6000 Welch, Suite A-2, El Paso, TX 
79905. 

Period: December 1991-January 1995. 

Grantee: Texas Department of Human Services, 701 West 51st St., Austin, TX 
78714. 

Independent Living for Seniors 
Period: March 1992-April 1995. 

Grantee: Rochester General Hospital, 1425 Portland Ave., Rochester, NY 14621. 
Period: March 1992-April 1995. 

Grantee: New York Department of Social Services, 40 North Pearl St., Albany, 
NY 12243. 



52 



Up to seven additional sites will be phased in over the next 2 years. A contract to 
evaluate the PACE demonstration was awarded in June 1991. Presentations of the 
demonstration implementation and evaluation issues were given at the following 
national meetings: American Public Health Association annual meeting and Geron- 
tological Society of America annual meeting. 

Evaluation of the Program for All-inclusive Care for the Elderly Demonstration 
Period: June 1991-February 1996. 
Total Funding: $4,486,514. 

Contractor: Abt Associates, Inc., 55 Wheeler St., Cambridge, MA 02138-1168. 
Investigator: Laurence Branch, Ph.D. 

The Program for All-Inclusive Care for the Elderly (PACE) demonstration repli- 
cates a unique model of managed-care service delivery for 300 very frail community- 
dwelling elderly, most of whom are dually eligible for Medicare and Medicaid cover- 
age and all of whom are assessed as being eligible for nursing home placement ac- 
cording to the standards established by participating States. The model of care in- 
cludes as core services the provision of adult day health care and multidisciplinary 
team case management through which access to and allocation of all health and 
long-term care services are arranged. This model is financed through prospective 
capitation of both Medicare and Medicaid payments to the provider. The purpose of 
the evaluation is to examine PACE sites before and after assumption of full finan- 
cial risk, with the purpose of determining whether the PACE model of care, as a 
replication of the On Lok Senior Health Services model of care, is cost effective rela- 
tive to the existing Medicare and Medicaid systems. Specific evaluation questions 
relate to the model of care and the effects of the model on participant utilization, 
expenditures, and outcomes. 

An initial round of site visits has been completed, and the evaluation design and 
data collection plan are being revised based on these site visits. 

Implementation of the Home Health Agency Prospective Payment Demonstration 
Period: June 1990-June 1995. 
Total Funding: $1,629,606. 

Awardee: Abt Associates Inc., 55 Wheeler St., Cambridge, MA 02138-1168. 
Investigator: Henry Goldberg. 

This contract implements and monitors the demonstration design developed by an 
earlier contract with Abt Associates Inc., The Home Health Agency Prospective 
Payment Demonstration. The project will implement a demonstration testing two 
alternative methods of paying home health agencies (HHAs) on a prospective basis 
for services furnished under the Medicare program. The prospective payment ap- 
proaches to be tested are Phase I, payments per visit by type of discipline, and 
Phase II, payments per episode of Medicare-covered home health care. Home health 
agency participation in the demonstration is voluntary. 

Following the initial home health agency recruitment, operations of the first 
phase of the demonstration began October 1, 1990. Forty-nine HHAs are participat- 
ing in Phase I. Developmental work involving case-mix payment adjustments in 
Phase II is ongoing. Implementation of the second phase testing the per episode pay- 
ment method is scheduled to begin in 1993. In each phase, HHAs that agree to par- 
ticipate are randomly assigned to either the prospective payment method or to a 
control group that continues to be reimbursed in accordance with the Medicare cur- 
rent retrospective cost system. Each HHA will participate in the demonstration for 
3 years. 

Evaluation of the Home Health Prospective Payment Demonstration 
Period: September 1990-June 1995. 
Total Funding: $2,858,676 (Phase I). 

Contractor: Mathematica Policy Research, Inc., P.O. Box 2393, Princeton, NJ 
08543-2393. 
Investigator: Barbara Phillips, Ph.D. 

The purpose of this contract is to evaluate the first phase of a demonstration de- 
signed to test the effectiveness of using prospective payment methods to reimburse 
Medicare-certified home health agencies (HHAs) for services provided under the 
Medicare program. In Phase I, a per visit payment method which sets a separate 
payment rate for each of six types of home health visits (i.e., skilled nursing, home 
health aide, physical therapy, occupational therapy, speech therapy, and medical 
social services) will be tested. Mathematica Policy Research will evaluate the effects 
of this payment method on HHAs' operations, quality of services HHAs deliver to 
Medicare beneficiaries, and Medicare expenditures. The contractor will also analyze 
the relationship between patient characteristics and the cost and use of HHA serv- 



53 



ices in order to develop improved methodologies for adjusting prospective payment 
rates for case-mix variations. 

The demonstration began on October 1, 1990. The contractor has submitted a 
design report, information collection clearance packages, several quarterly reports, 
and a case study report. The contractor is currently conducting case-mix analyses, 
as well as other analyses of HHA costs and service use patterns, to assist the Health 
Care Financing Administration in refining the per episode payment method that 
will be tested in Phase II of this demonstration. A special report on the results of 
the contractor's case-mix analyses is expected in winter 1993. Phase II of the demon- 
stration, which will test the per episode payment method, is scheduled to begin in 
late 1993. 

Quality Review for the Home Health Agency Prospective Payment Demonstration 
Period: September 1991-December 1994. 
Total Funding: $1,499,085. 

Contractor: New England Research Institute, Inc., 9 Galen St., Watertown, MA 
02172. 

This contract involves quality review of the care received by Medicare benefici- 
aries who are clients of the home health agencies that are participating in the 
Home Health Agency Prospective Payment System demonstration (HHA/PPS). The 
HHA/PPS demonstration is testing the costs and benefits of prospective payment 
for Medicare home health services compared to the current retrospective cost reim- 
bursement system. In order to assure that the incentives created under the HHA/ 
PPS demonstration do not result in the provision of inadequate home health care to 
Medicare beneficiaries, the New England Research Institute, Inc. (NERI), the qual- 
ity review contractor, implemented the quality assurance plan that calls for a 
review of patient records for a sample of Medicare beneficiaries receiving care 
under the HHA/PPS demonstration. If potential or actual problems are discovered, 
the contractor implements a defined protocol to address the situation. 

During the initial year of the contract, NERI staff completed all of the activities 
related to the start-up of the quality assurance plan, including baseline training of 
NERI nurse reviewers who are conducting the medical record reviews. NERI has 
begun the process of assessing patterns of problems within any given home health 
agency which may require educational follow-up or additional medical reviews. 

Develop and Demonstrate a Method for Classifying Home Health Patients to Predict 
Resource Requirements and to Measure Outcomes 
Period: June 1987-March 1991. 
Total Funding: $968,332. 

Awardee: Georgetown University, Georgetown School of Nursing, 3700 Reservoir 
Road, NW., Washington, DC 20007. 
Investigator: Virginia Saba, RN, Ed.D. 

The purpose of this project is to develop a method for classifying patients that will 
predict resource requirements and measure outcomes of Medicare patients in certi- 
fied home health agencies (HHAs). Data on 73 dependent variables were collected 
from the home health records of approximately 9,000 recently discharged Medicare 
patients drawn from a national sample of approximately 650 certified HHAs, strati- 
fied by size, ownership, and geographic location. The data are being analyzed, using 
multivariate statistical techniques to determine which variables are most predictive 
of resource requirements. The identified relevant variables will be incorporated into 
a classification method with an assessment tool that categorizes patients according 
to predicted resource requirements. A data base of participating HHAs and the 
characteristics of their Medicare patients will be created. 

Analysis of the data collected in the study indicated that patients' nursing diag- 
noses and nursing procedures are important variables in explaining home health re- 
source use and costs. The final report entitled "Develop and Demonstrate a Method 
for Classifying Home Health Patients to Predict Resource Requirements and to 
Measure Outcomes" is available from the National Technical Information Service, 
accession number PB177013. 

Analysis of Home Health Cost and Service Utilization Issues 
Period: September 1991-November 1992. 
Funding: $189,607. 

Awardee: University of Minnesota Research Center, 1919 University Ave., St. 
Paul, MN 55104. 

Investigator: Barbara Phillips, Ph.D. 

For this study, researchers will prepare a synthesis of research findings related to 
prospective payment and analyze Medicare claims data to examine several aspects 



54 



of prospective payment methodologies for home health agencies, such as outlier 
cases and volume adjustments. These analyses will provide information to the 
Health Care Financing Administration (HCFA) for use in the future development of 
prospective payment methodologies for Medicare home health services. 

The awardee has submitted draft papers on episode length, volume adjustors, and 
a review of the literature related to Medicare home health prospective payment. 
These are currently under review within HCFA. 

Home Care Quality Studies 
Period: October 1989-September 1993. 
Total Funding: $2,848,782. 

Contractor: University of Minnesota, School of Public Health, Box 197, 420 Dela- 
ware St., SE., Minneapolis, MN 55455. 
Investigator: Robert Kane, M.D. 

For this study, the contractor will carry out research on the following topics: 
— Quality of long-term care services in community-based and custodial settings. 
— Effectiveness of (and need for) State and Federal protections for Medicare bene- 
ficiaries that ensure adequate access to nonresidential long-term care services 
and protection of consumer rights. 
The contractor will focus on in-home care, examining traditional home health 
services that are reimbursed by Medicare and Medicaid, as well as personal care 
and supportive services which have more recently been covered by Federal and 
State sources of funding. Primary project tasks include: 
— Development of a taxonomy clarifying the various objectives and goals ascribed 
to home and community-based care from the various perspectives of consumers, 
payers, and care providers. 
— Development and feasibility-testing of a survey design that would measure the 

extent of, need for, and adequacy of home care services for the elderly. 
— A study of variations in labor supply and related effect(s) on home care quality, 

as well as factors that contribute to these variations. 
— Recommendations to improve the quality of home and community-based serv- 
ices by identifying best practices and promising quality assurance approaches. 
The first project task (development of a taxonomy of goals and objectives) has 
been completed, and a report on this component has been received. The University 
of Minnesota is continuing work on each of the remaining primary tasks. The final 
report for this contract is expected in September 1993. 

Study of Home Health Care Quality and Cost Under Capitated and Fee-for-Service 
Payment Systems 
Period: June 1987-June 1993. 
Total Funding: $1,683,773. 

Awardee: Center for Health Policy Research, 1355 South Colorado Blvd., Denver, 
CO 80222. 

Investigator: Peter Shaughnessy, Ph.D. 

This project is designed to evaluate service utilization, quality, and cost of Medi- 
care home health care provided under capitated and noncapitated (fee-for-service) 
payment systems. The Center for Health Policy Research will collect patient-level, 
case-mix, and service use data on a sample of approximately 4,000 patients from 44 
agencies nationwide. A random and stratified patient sample will be drawn from 
both fee-for-service and capitated payment environments to assess and compare cost 
effectiveness of care, quality of care, and incentives to admit and provide care in the 
two payment environments. Secondary data analysis will also be completed on a 
sample of 10,000 Medicare beneficiaries using Medicare claims data to compare serv- 
ice use patterns among post-hospital Medicare patients discharged to skilled nursing 
facilities, home health care facilities, and the community, as well as Medicare home 
health patients admitted from the community. 

Primary data • collection has been completed and data processing is underway. 
Eight study papers have been received, reviewed and accepted. The Final Report is 
expected to be complete in spring 1993. 

Testing the Predictive Validity of Using Medicare Claims Data to Target High-Cost 
Patients 

Period: August 1991-November 1992. 
Total Funding: $139,898. 

Awardee: Brandeis University Research Center, 415 South St., Waltham, MA 
02254. 

Investigator: Christine Bishop, Ph.D. 



55 



For this study, Brandeis will investigate the feasibility of using historical Medi- 
care claims data of patients hospitalized with certain primary diagnoses in order to 
identify a subset of patients who are more likely to incur high levels of Medicare 
reimbursements in the future. Analysis will be restricted to a sample of hospital pa- 
tients with selected illnesses where past research indicates the specific patient diag- 
noses eventually results in higher Medicare costs, and it is determined that targeted 
case management or coordinated care programs can be potentially effective (based 
on research and/or professional clinical judgment) in reducing overall health care 
costs. 

A preliminary study design has been completed, as well as construction of an ana- 
lytic research file. The final report for this project is anticipated in winter 1993. 

Evaluation and Technical Assistance of the Medicare Alzheimer's Disease Demon- 
stration 

Period: September 1989-September 1994. 
Total Funding: $2,999,812. 

Contractor: Institute for Health and Aging, University of California, San Francis- 
co, Building N631, San Francisco, CA 94134. 
Investigator: Robert Newcomer, Ph.D. 

The Medicare Alzheimer's Disease Demonstration was authorized by Congress 
under Section 9342 of Public Law 99-509 to determine the effectiveness, cost, and 
impact on health status and functioning of providing comprehensive services to 
beneficiaries who have dementia. Two models of care are being studied under this 
project. Both provide case management and a wide range of in-home and communi- 
ty-based services, including homemaker and personal care services, adult day care, 
and education and counseling for family caregivers. The two models vary by the in- 
tensity of the case management beneficiaries and their families receive and the 
level of Medicare reimbursement that is available each month to pay for demonstra- 
tion services. Clients are responsible for a 20-percent coinsurance just as they are 
under the regular Medicare program. There are four Model A and four Model B 
sites participating in this demonstration. Under Model A, each site has a case man- 
ager to client ratio of 1:100. Monthly client expenditure caps which have been ad- 
justed for geographical cost variations range from $336 to $407. Model A sites are 
located in Memphis, Tennessee; Portland, Oregon; Rochester, New York; and 
Urbana, Illinois. The case management ratio in the Model B sites is 1:30 and their 
monthly expenditure caps are between $549 and $662. Model B sites are located in 
Cincinnati, Ohio; Miami, Florida; Minneapolis, Minnesota; and Parkersburg, West 
Virginia. Major questions to be addressed by the evaluation include: 
— What factors are associated with the cost effectiveness of providing an expanded 
package of home care and community-based services to Medicare beneficiaries 
with Alzheimer's disease or related disorders? 
— How do various services impact on the health status and functioning of demen- 
tia patients and their caregivers? 
— What are the effects of providing community-based services on caregiver burden 
and stress? 

— Do additional home care services delay or prevent institutionalization of benefi- 
ciaries with dementia? 

A provision in the Omnibus Budget Reconciliation Act of 1990 extended the dem- 
onstration from 3 to 4 years. It also increased the funding for the project's adminis- 
trative and service costs from $40 million to $55 million and for the evaluation from 
$2 million to $3 million. During the first 2 years of the demonstration, the sites en- 
rolled approximately 6,000 Medicare beneficiaries, including both treatment and 
control group members. However, there has been an unexpectedly high client attri- 
tion rate. Most of the individuals who have left the project have been disenrolled 
because of death or nursing home placement. The demonstration is scheduled to end 
in May 1993. A final report indicating the project's findings and recommendations 
for possible legislative changes will be available in September 1994. 

National Recurring Data Set Project: Ongoing National and State-by-State Data Col- 
lection and Policy/Impact Analysis on Residential Services for Persons With 
Developmental Disabilities 
Period: August 1991-September 1992. 
Total Funding: $50,000. 

Awardee: The Administration on Developmental Disabilities, Room 336-D, Hubert 
H. Humphrey Building, 200 Independence Ave., SW., Washington, DC 20201. 
Investigator: Charles Lakin, Ph.D. 

The Health Care Financing Administration's transfer of funds to the Administra- 
tion on Developmental Disabilities (ADD) is in support of an existing ADD grant to 



56 



the Institute on Community Integration, Center for Residential and Community 
Services at the University of Minnesota. This supplement will support the conduct 
of secondary data analyses and the production of a report that will describe and 
update the status of persons with mental retardation and related conditions in in- 
termediate care facilities for the mentally retarded (ICFs/MR), Medicaid waiver pro- 
grams, and nursing homes funded under Medicaid in order to assist in the evalua- 
tion of Medicaid services for persons with these conditions, and to point out areas in 
need of reform. The report will include: 

— A background description of the key Medicaid programs of interest. 

— State-by-State and national statistics on ICFs/MR, Medicaid home and commu- 
nity-based services, and nursing home utilization. 

— A description of the characteristics of ICFs/MR and their residents, with com- 
parative statistics for noncertified facilities. 

The final report for this project was received in March 1992 and is being sent to 
the National Technical Information Service. 

The Development of Long-Term Care Reform Strategy for New York's Office of 
Mental Retardation and Developmental Disabilities 
Period: June 1988-December 1990. 
Total Funding: $115,581. 

Awardee: New York State Department of Social Services, Division of Medical As- 
sistance, 40 North Pearl St., Albany, NY 12243. 
Investigator: Max Chmura. 

The New York Office of Mental Retardation and Developmental Disabilities is 
conducting a 2V2-year project to develop a comprehensive plan and waiver applica- 
tion that would reform the financing, regulation, and service delivery of the mental- 
ly retarded and developmentally disabled (MR/DD) system in three districts cover- 
ing eight New York counties. The State considers the demonstration as the first 
step toward statewide implementation. The objectives are to: 

— Develop a financing system that will improve services to the MR/DD population 
by expanding the number and types of people to be served and the types of serv- 
ices to be provided. 

— Change the manner in which quality of care is assured. 

— Constrain growth in Federal expenditures for these services. 

Waivers would alter the Medicaid basis of payment, revise the State Medicaid 
plan requirements, change how Medicaid funds can be used, and implement revised 
quality assurance regulations. The demonstration will test an alternative financing 
approach that approximates recently formulated departmental policy directions as 
developed by the Department of Health and Human Services working group on in- 
termediate care facilities for the mentally retarded. The project represents a major 
test of reform in the delivery of services for persons who are developmentally dis- 
abled. 

Both national and State-level advisory panels have been convened and issue 
papers have been completed. The State submitted and received approval of a Medic- 
aid 2176 home and community-based care waiver to implement this project. The 
waiver program was implemented in Fall 1991. A final report was received and ac- 
cepted in Spring 1992. 

Analysis and Comparison of State Board and Care Regulations and Their Effect on 
the Quality of Care in Board and Care Homes 
Period: September 1991-September 1992. 
Total Funding: $200,000. 

Awardee: Office of the Assistant Secretary for Planning and Evaluation, Room 
410-E, Hubert H. Humphrey Building, 200 Independence Ave., SW., Washington, 
DC 20201. 

Investigator: Catherine Hawes, Ph.D. 

The Health Care Financing Administration (HCFA) has transferred funds to the 
Office of the Assistant Secretary for Planning and Evaluation (ASPE) in support of 
an existing contract with the Research Triangle Institute (RTI). ASPE has funded 
RTI to conduct a study to examine the relationship between the type and amount of 
State regulation and the quality of care in board and care homes. In addition, the 
study will document the characteristics of a large sample of board and care homes, 
their residents, and owners/operators. HCFA's support will enable the contractor to 
increase the project's sample size to allow for analysis of the relationship between 
additional characteristics of board and care homes and to conduct a more detailed 
field test. 

The following ten states have been selected to participate in the study: New 
Jersey, Texas, Oklahoma, Georgia, Kentucky, Arkansas. Florida, Illinois, California, 



57 



and Oregon. Survey instruments are currently under revision and pre-test activities 
are underway in facilities in North Carolina and the District of Columbia. Data col- 
lection activities are expected to begin in the Fall of 1991. 

Prior and Concurrent Authorization Demonstrations 
Period: September 1987-August 1992. 
Total Funding: $827,200. 

Contractor: Lewin/ICF, 9300 Lee Highway, Fairfax, VA 22031-1207. 
Investigator: Barbara Manard, Ph.D. 

Under Section 9305 of Public Law 99-509, the Secretary of Health and Human 
Services is required to conduct a demonstration program concerning prior and con- 
current authorization for post-hospital extended care services and home health serv- 
ices furnished under Part A or Part B of Title XVIII. This legislation responds to 
concerns expressed by home health agencies and skilled nursing facilities (SNFs) 
that under the current system of Medicare payment they cannot adequately predict 
what services the fiscal intermediaries (FIs) will deny as noncovered. In recent 
years, the number of visits denied by FIs has increased steadily. It is hypothesized 
that prior authorization (PA) and concurrent authorization (CA) payment approach- 
es will reduce the number of services denied without increasing Medicare expendi- 
tures. Under PA, providers submit treatment plans to FIs for review prior to the 
start of care; under CA, plans of treatment are submitted when care begins. In both 
approaches, the provider receives notification from the FI about how many services 
will be covered. This provides greater certainty about coverage and payment before 
services are given. The law requires that the demonstration include at least four 
projects and be initiated by January 1, 1987, and that the Secretary must evaluate 
the demonstration and report to Congress on the evaluation. The evaluation and 
report must address: 

— The administrative and program cost for prior and concurrent authorization 
compared with the current system of retroactive claims review. 

— The impact on access and availability of post-hospital services and timeliness of 
hospital discharges. 

— The accuracy and cost savings of payment determinations and rates of claims 
denials compared with the current system. 

The Bureau of Program Operations, Health Care Financing Administration 
(HCFA), implemented a home health CA pilot project in July 1987. This project was 
initiated in Illinois and in the entire Dallas region and is still in progress. Lewin/ 
ICF implemented the SNF demonstration in September 1989 at sites in Indiana and 
Tennessee. Lewin/ICF is responsible for evaluating both the home health pilot 
project and the SNF demonstration. 

A Report to Congress based on Lewin/ICF's preliminary evaluation of the home 
health project and the design of the SNF project was submitted to Congress in 
August 1990. The SNF prior authorization demonstration ended in November 1990. 
Both an update of the home health pilot project and an evaluation of the SNF dem- 
onstration have been submitted to HCFA and are under review. 

Long-Term Care Supply and Medicare Hospital Utilization 
Period: August 1989-August 1990. 
Total Funding: $47,986. 

Awardee: Abt Associates, Inc., 55 Wheeler St., Cambridge, MA 02138-1168. 
Investigator: Robert Schmitz, Ph.D. 

The purpose of this project was to investigate how local variations in the avail- 
ability of nursing home beds affect Medicare hospitalization rates. Effects on the 
number of admissions, the number of hospital readmissions, the number of hospital 
days used, and the costs per Medicare Part A enrollee were evaluated. Urban and 
rural differences were assessed. The impacts of community long-term care services, 
Medicare risk-contract health maintenance organization services, and the prospec- 
tive payment system on Medicare Part A utilization were evaluated. 

A final report was received in May 1992, and is being sent to the National Techni- 
cal Information Service. Findings from the report were presented at the Association 
for Health Services Research and American Public Health Association annual meet- 
ings. The author concludes that while increased availability of nursing home beds 
was found to reduce the average length of hospital stays, it also appeared to stimu- 
late rather than reduce hospital admissions for aged beneficiaries living in urban 
areas and to increase the likelihood of rehospitalization, contrary to the study's hy- 
potheses. Moreover, the increase in the probability of hospital admission associated 
with the addition of nursing home beds was most pronounced among the oldest 
beneficiaries, those most likely to use nursing home care. Furthermore, the relation 



58 

between nursing home beds and hospital use was positive even after controlling for 
persistent county-specific effects. 

Impacts of Long-Term Care Supply Differences on Medicare Service Use 
Period: August 1990-December 1991. 
Total Funding: $80,204. 

Awardee: Brandeis University Research Center, 415 South St., Waltham, MA 
02254. 

Investigator: Christine Bishop, Ph.D. 

For this study, Brandeis identified and assessed methodological and practical 
problems associated with a potential investigation of access to long-term care (LTC) 
service and the resulting impact on beneficiary use of Medicare-covered services. 
These services include hospital care, Medicare-covered home health care, and Medi- 
care-covered skilled nursing facility care. The project directly addresses issues, 
which have been studied in various models, of the effects of LTC access and supply 
on utilization of health services. Brandeis has also developed a suggested study 
design on this topic. 

The final report for this study, entitled "Impacts of LTC Supply Differences on 
Medicare Services Use: A Conceptual Model," has been accepted and will be submit- 
ted to the NTIS. 

Urban/Rural Variation in Home Health Agency and Nursing Home Services 
Period: September 1989-December 1991. 
Total Funding: $155,096. 

Awardee: Brandeis University Research Center, 415 South St., Waltham, MA 
02254. 

Investigator: Christine Bishop, Ph.D. 

Brandeis University and The Urban Institute compared urban and rural home 
health services and nursing home services to determine variation between provider 
characteristics and service utilization patterns. The underlying cost structures of 
urban and rural home health agencies were studied as well. This study is national 
in scope and utilizes several Medicare data bases for analysis. 

The following reports have been prepared by The Urban Institute under this 
study: 

— "Home Health Use Patterns in Rural and Urban Areas: Are They Different?" 
— "Access to Home Health Services: Is it a Problem for the Rural Elderly?" 
— "The Provision of Home Health Services: Is it a Problem in Rural Areas?" 
— "The Provision of Nursing Home Services: Is there a Problem in Rural Areas?" 
— "The Characteristics of Nursing Home Residents: An Urban-Rural Compari- 
son." 

— "Explaining Urban-Rural Differences in Skilled Nursing Facility Benefit Use." 
— "Medicare Costs in Urban and Rural Nursing Homes: Are Differential Pay- 
ments Required?" 

These reports indicate that the proportion of Medicare beneficiaries using home 
health services and the average number of visits per user are greater in urban 
areas. Within rural areas, use rates increase with population density. A greater pro- 
portion of home health visits provided to rural home health users is skilled nursing 
services, possibly substituting for reduced availability of physical, speech, and occu- 
pational therapists in rural areas. Researchers found that the supply of nursing 
home beds per 1,000 Medicare beneficiaries is higher in rural areas, but rural nurs- 
ing homes are more likely to provide intermediate care facility level of care rather 
than skilled nursing facility (SNF) level of care. Access to the Medicare SNF benefit 
appears to be greatest in large metropolitan areas, followed by rural areas, with en- 
rollees in small and medium-sized areas having less accessibility to beds. The hospi- 
tal swing-bed program appears to be an important element of access to post-hospital 
SNF level of care in rural areas. All reports have been completed and will be Sent to 
the National Technical Information Service in winter 1993. 

Analysis of Costs, Patient Characteristics, Access, and Service Use in Urban/Rural 
Home Health Agencies 
Period: September 1989-August 1991. 
Total Funding: $103,420. 

Awardee: University of Minnesota Research Center, 1919 University Ave., St. 
Paul, MN 55104. 

Investigator: John Nyman, Ph.D. 

The purpose of this project was to study urban and rural differences in home 
health agency costs, patient characteristics, access to care, and service utilization 
patterns in the State of Wisconsin. The study included two types of analyses: 



59 



— Costs, patient characteristics, and service utilization patterns using home 
health data from Wisconsin. 

— Access to health care services using patient-level Medicare data. For the second 
type of analysis, Mathematica Policy Research, Inc., as subcontractor for the 
project, applied two of the "Aftercare Guidelines" to the Medicare plan of treat- 
ment data to develop a measure of access between urban and rural recipients of 
home health care. 

This project has been completed. Two reports were prepared. In the first, "Access 
to Medicare Home Health Agencies: Differences Between Urban and Rural Areas," 
researchers indicate that Medicare home health users in rural areas of Wisconsin 
used fewer physical therapy services than those in urban areas. It appears that 
rural home health agencies may have compensated by providing more restorative 
skilled nursing services. In the second, "Analysis of Costs, Patient Characteristics, 
Access, and Service Use in Urban and Rural Home Health Agencies," researchers 
estimate a total cost function for home health agency costs in urban and rural areas 
of Wisconsin. Findings indicate that urban residents in Wisconsin were more likely 
to be home health patients and to receive more visits, but that these differences 
may be explained by differences in the types of patients being served in these areas. 
Both reports will be sent to the National Technical Information Service in winter 
1993. 

Study of Medicare Home Health Agency Use of the Home Health Case Management 
Benefit 

Period: September 1991-January 1992. 
Total Funding: $76,836. 

Awardee: Project HOPE Research Center, 2 Wisconsin Circle, Suite 500, Chevy 
Chase, MD 20815. 

Investigator: Robyn Stone, Ph.D. 

For this study, researchers will analyze Medicare claims and plan of treatment 
data for home health agencies (HHAs) in order to examine the provision of skilled 
patient management by HHAs. Recent information suggests that the use of this 
service has significantly increased in recent years as a result of changes in the in- 
terpretation of coverage requirements for home health care. This study will provide 
the Health Care Financing Administration with information on the characteristics 
of patients who are receiving this service, and the types of HHAs that are furnish- 
ing the service. 

Construction of data/analytical files is almost complete. These files will subse- 
quently be used to conduct episode analyses and to link plan-of-treatment informa- 
tion with Medicare claims data. The final report for this project is due January 
1993. 

Nurse Practitioner/ Physician Assistant Aggregate Visit Demonstration 
Period: September 1990-September 1993. 
Total Funding: $130,538. 

Awardee: The Urban Medical Group, 545 D Centre St., Jamaica Plain, MA 02130. 
Investigator: Rita Chang, Ph.D. 

Under section 6114(e) of Public Law 101-239, the Medicare program provides Part 
B coverage to nursing home residents for medical visits rendered by nurse practi- 
tioners who are members of a physician /physician assistant/nurse practitioner 
team. Under this legislation, the number of visits supplied to any nursing home pa- 
tient is limited to an average of 1.5 visits per month. Section 6114(e) mandates a 
demonstration project under which the visit limitation would be applied on an aver- 
age basis over the aggregate total of residents receiving services from members of 
the provider team. A preliminary Massachusetts demonstration project, Case Man- 
aged Medical Care for Nursing Home Patients, used nurse practitioners and physi- 
cian assistants to provide visits to nursing home patients. This demonstration ended 
on September 30, 1990. Many of the original Massachusetts demonstration sites are 
also participating in this second project. 

The project is being conducted in two phases. The first phase (primarily for plan- 
ning and development) was completed in March 1992. The second phase, which in- 
cludes the actual implementation and operation of the demonstration, began in 
April 1992. Negotiations with the Medicare carrier, Massachusetts Blue Cross and 
Blue Shield, are almost complete. The Urban Medical Group has arranged for ap- 
proximately 16 provider groups (medical teams) to participate in this demonstration. 
The final report for this project is expected in July 1993. 



65-505 - 93 - 3 



60 



Future Directions For Long-Term Care 

During 1992, HCFA devoted substantial resources to the further development and 
implementation of demonstrations to test the cost-effectiveness of prospective pay- 
ment systems for nursing homes and home health agencies implement and monitor 
new coordinated care systems for the frail elderly, and develop outcome-oriented 
quality measures to improve the quality of care in these settings. 

We will continue to test alternative financing schemes for long term care services, 
including preparations for implementation of the Multi-State Nursing Home Case 
Mix and Quality Demonstration. The Home Health Agency Prospective Payment 
Demonstration will continue during 1993, and we will continue current analyses to 
develop a case-mix adjusted per-episode payment methodology to be implemented in 
the second phase of the demonstration. Developmental activities related to the Com- 
munity Nursing Organization Demonstration will continue, including development 
of detailed operating plans and protocols, in preparation for implementation of the 
demonstration with the four CNO sites. 

We will continue our efforts to develop, operate, and evaluate coordinate care sys- 
tems for the frail elderly, including the Medicare Alzheimer's Disease Demonstra- 
tion, the Program for the All-inclusive Care of the Elderly Demonstration, and the 
Social /Health Maintenance Organization Demonstration. 

We also will continue the development and testing of outcome-oriented measures 
of quality for nursing home and home health services and assessment of the applica- 
bility of using payment generated data to monitor quality. In this light, we will con- 
tinue to develop a multi-State demonstration integrating resident assessment and 
case-mix payment data with the quality assurance process for nursing home provid- 
ers. 

Another very important area that will continue to be explored is alternative fi- 
nancing mechanisms for long term care. Although the majority of the elderly are 
covered by both Medicare and supplemental insurance, a large portion of long term 
care services remain uncovered. Medicaid covers long term nursing care, but only 
after the elderly individuals have depleted their resources. Research is continuing 
that will identify the sources of financing for long term care at various points 
throughout institutionalization. This research will further examine characteristics 
of individuals who come to rely upon Medicaid for payment for their care. By identi- 
fying the risks associated with nursing home use, we hope to be able to propose im- 
proved methods of paying for this care. Alternatives being studied as a solution for 
some of the elderly's problems in financing long term care are life care centers and 
private long term care insurance. Other ORD financing research continues to exam- 
ine various States' reimbursement of long term care in order to assess the feasibility 
of recommending policy changes, e.g., prospective payment for SNF care. 

We will continue to support data collection and data analyses from projects that 
gather detailed information from representative national samples or other large seg- 
ments of the elderly population. Research is continuing on the estimated future 
acute and long term care utilization based on information from available surveys on 
the morbidity, disability, and mortality of different birth cohorts. We will continue 
initiatives to make additional data bases available for research and analysis, such as 
the 1989 Long Term Care Survey and State Medicaid data. 

In 1993, we also will begin an evaluation of the Community Supported Living Ar- 
rangements (CSLA) program, mandated by section 4712 of OBRA 90. Eight States 
are receiving funding through this optional Medicaid State plan service to develop 
CSLA programs, in which service individuals with mental retardation and related 
conditions living in the community independently, with their family or in a home of 
three or fewer individuals. HCFA will also expand its research activities related to 
the nonelderly disabled. 

Social Health Maintenance Organization Project for Long-Term Care 
Period: August 1984-December 1995. 
Awardees: See Below. 

In accordance with Section 2355 of Public Law 98-369, this project was developed 
and is currently implementing the concept of a social health maintenance organiza- 
tion (S/HMO) for acute and long-term care. A S/HMO integrates health and social 
services under the direct financial management of the provider of services. All serv- 
ices are provided by or through the S/HMO at a fixed annual prepaid capitation 
sum. Four sites have been selected to participate in this project. 

Of the four S/HMO demonstration sites selected, two are HMOs that have added 
long-term care services to their existing service packages and two are long-term care 
providers that have added acute care service packages. The demonstration sites uti- 
lize Medicare and Medicaid waivers, and all initiated service delivery by March 



61 



1985. During the first 30 months of operation, Federal and State governments 
shared financial risk with the sites. This risk sharing ended August 31, 1987. This 
demonstration was extended twice by legislation. The current legislation (P.L. 101- 
508) extends the demonstration period through December 31, 1995. The S/HMO 
sites are: 

Grantee: Elderplan, Inc., 6323 Seventh Avenue, Brooklyn, NY 11220. 

Grantee: Group Health, Inc., and Ebenezer Society, 2829 University Avenue, SE., 
Minneapolis, MN 55414. 

Grantee: Kaiser-Permanente Center for Health Research, 4610 Southeast Belmont 
Street, Portland, OR 97215-1795. 

Grantee: Senior Care Action Network, 521 East Fourth Street, Long Beach, CA 
90802. 

Analysis of Utilization and Cost Data From Comprehensive Outpatient Rehabilita- 
tion Facilities 
Period: August 1991 -September 1992. 
Total Funding: $80,890. 

Awardee: The RAND Policy Research Center. 
Investigator: Joan Buchanan, Ph.D. 

The RAND Policy Research Center will provide information on the utilization 
patterns of comprehensive outpatient rehabilitation facilities (CORFs) including the 
types of Medicare patients being treated, and the composition and duration of serv- 
ices. The types of patients and the patterns of care for Medicare patients treated in 
CORFs will also be compared with those receiving outpatient rehabilitation services 
in other settings including hospital outpatient departments, independent rehabilita- 
tion agencies, and home health agencies. 

Analysis of the data is underway and a draft final report is expected in fall 1992. 

Prospective Payment System and Post-Hospital Care: Use, Cost, and Market Changes 
Period: September 1985-January 1990. 
Funding: $706,118. 

Awardee: Georgetown University, Center for Health Policy Studies, 2233 Wiscon- 
sin Avenue, NW., Washington, DC 20007. 
Investigator: William Scanlon, Ph.D. 

The purpose of the project is to determine how much the hospital prospective pay- 
ment system (PPS) shifts care from the hospital to skilled nursing facilities (SNFs) 
and home health providers and to analyze the impact of this shift on total costs to 
Medicare and on changes in SNF characteristics that are likely to cause an increase 
in use by Medicare beneficiaries in the future. Medicare claims will be analyzed to 
determine how PPS has affected total service use (i.e., hospital, SNF, and home 
health) and costs for hospital patients. In addition, SNFs will be surveyed to identify 
changes in nursing home patients, services, and market structure likely to affect 
Medicare use. The survey will be supplemented with data from the Medicare/ Medic- 
aid Automated Certification System (MMACS), SNF cost reports, and other sources. 

A draft final report has been received and is under review. When it is accepted, it 
will be made available through NTIS. 

Multistats Case-Mix Payment and Quality Demonstration 
Period: May 1990-June 1996. 
Funding: $981,718. 

Awardee: New York State Department of Health, Room 1683, Corning Tower, 
Albany, NY 12237. 

Investigator: David Wilcox. 

New York State will participate in the Multistate Nursing Home Case-Mix and 
Quality (NHCMQ) Demonstration presently in its development phase. The objective 
of the demonstration is to test the feasibility and cost effectiveness of a case-mix 
payment system for nursing facility services under Medicare and Medicaid that are 
based on a common patient classification system. The addition of New York to the 
demonstration enhances the Health Care Financing Administration's ability to 
roject the results of the demonstration on a national basis. New York represents a 
eavily regulated, northern industrialized area with larger, high-cost nursing facili- 
ties that are medically sophisticated and highly skilled. Sixteen percent of the na- 
tional Medicare skilled nursing facility days are incurred in New York State. New 
York is uniquely suited for inclusion in this demonstration because it has already 
implemented a complementary system for its Medicaid nursing facility payment 
program. 

In early 1991, project staff completed the minimum data set field test in 25 facili- 
ties on 993 residents. These data have been added to the data base analyzed to de- 



62 



velop the new NHCMQ Medicare /Medicaid classification system. The inclusion of 
the New York data have resulted in the addition of a very high rehabilitation group 
to the upper end of the classification. The State has implemented the minimum 
data set plus (MDS+) statewide as their resident assessment instrument. In Novem- 
ber 1992, the State will begin receiving the information monthly from all facilities. 
The State is conducting analyses of 1990 Medicare cost report data, MEDPAR Part 
A skilled nursing facility stay data and New York patient review instrument (PRI) 
data for use in developing the demonstration Medicare case-mix payment system. 
The demonstration is expected to become operational in July 1993. 

The Use of Medicaid Reimbursement Data in the Nursing Home Quality Assurance 
Process 

Period: June 1988-February 1993. 
. Funding: $542,389. 

Awardee: Center for Health Systems Research and Analysis, University of Wis- 
consin-Madison, Room 1163, WARF Office Bldg., 610 Walnut Street, Madison, WI 
53705. 

Investigator: David Zimmerman, Ph.D. 

The purposes of this project are to assess the feasibility of using Medicaid reim- 
bursement data to target facilities and residents in the nursing home quality assur- 
ance survey process and to develop a set of quality of care indicators (QCIs) using 
resident assessment data. Medicaid reimbursement data on medication use, sentinel 
health event, and other indicators are being provided to surveyors in preparation 
for the field survey to help target facilities for more intensive review, identify spe- 
cific areas of deficient care, and identify individual residents for more detailed 
review. The objectives of the project are to: 

Convert reimbursement data into specific QCIs. 

Identify the Federal regulations for which the use of QCIs has the greatest 
potential benefit. 

Develop and demonstrate in one State (Wisconsin) procedures for providing 
QCIs to survey staffs. 
Assess the potential for implementing the system in other States. 
Develop a set of quality indicators (QIs), using resident assessment informa- 
tion, sometimes in combination with claims data, that can be used in the survey 
process as part of The Multistate Nursing Home Case-Mix and Quality 
(NHCMQ) Demonstration. 
A program was implemented on December 1, 1990, in which a randomly assigned 
group of survey teams in two Wisconsin regions were provided information on 33 
QCIs for each nursing facility prior to the survey. Surveyors used the QCI informa- 
tion in selecting residents for indepth review and in determining whether care defi- 
ciencies should be cited. The surveyors completed and returned a feedback report 
that documented the results of QCI residents' investigations. Through November 
1991, QCIs were used in approximately 120 surveys, in addition to the 17 surveys in 
which they were used in a pilot study. A report on the QCI demonstration is expect- 
ed in fall of 1992. 

Activities continue on the development of QIs for the Multistate NHCMQ Demon- 
stration. Twelve quality areas (domains) have been identified. Within these domains, 
158 different constellations of process, outcome and risk factors have been analyzed 
using resident set information from facilities in Kansas, Maine, Mississippi and 
South Dakota. This analysis will be reviewed by a research oriented quality panel, 
with the intent of reducing the list from which the QIs to be pilot tested by the 
States in spring 1993 will be selected. A clinical work group consisting of more than 
60 nurses, social workers, rehabilitation specialists, physicians, and other health 
care professionals, as well as case-mix States' project staff make recommendations 
regarding the QIs to be pilot tested, and those that should be researched for possible 
future use. It is expected that no more than 30 QIs will be proposed for use in the 
operational phase of the demonstration in July 1993. 

Texas Nursing Home Case-Mix Demonstration 
Period: September 1987-March 1993. 
Funding: $532,830. 

Awardee: State of Texas Department of Human Services, P.O. Box 149030 (MC-E- 
601); Austin, TX 78714-9030. 
Investigator: Pam Coleman. 

This Texas Department of Human Services project has two parts. The first part 
was to develop, implement, and evaluate a Medicaid prospective case-mix payment 
system. The payment system is based on feasibility studies sponsored by the Health 



63 



Care Financing Administration (HCFA). The major Medicaid objectives of this part 
of the project are to: 

Match payment rates to resident need. 

Promote the admission of heavy-care patients to nursing homes. 
Provide incentives to improve quality of care. 
Improve management practices. 

Demonstrate administrative feasibility of the new system. 
The second phase of the project is to develop and pilot test a case-mix adjusted 
prospective payment system for Medicare patients in skilled nursing facilities. The 
objective for the Medicare pilot test is to develop and implement the administrative 
processes for a Medicare prospective payment system in 4 facilities based on a re- 
source utilization group (RUG) classification. The index that will be used for the 
classification of Medicare patients is the RUG-T18, which uses the same clinical 
groups and the activities of daily living (ADD scale used in the New York RUGs II 
system. The difference occurs in the expanded rehabilitation groups for Medicare 
patients. Texas will use a quasi-experimental design for the Medicare pilot test to 
compare the effect of introducing case-mix payment in an experimental catchment 
area versus continuing the flat-rate, cost-based system in a control catchment area. 
The State is using a pre-post design for the Medicaid system. The case-mix classifi- 
cations are based on a review of six different systems in which the New York RUGs 
II explained the greatest variance of staff time. The case-mix indexes borrow major 
elements of the RUGs II system and some of the rationale from the Minnesota 
system. The Texas index of level of effort (TILE) uses four clinical groups to form 
clusters and develop subgroups using an ADL scale. Two third-party evaluations 
will be used — one of data reliability and a second of the validity of the data analysis 
methods. 

During the first year, the TILE and RUG-T18 indexes were reviewed for compat- 
ibility. The Medicaid payment system became operational statewide under the 
Texas Medicaid State plan in April 1989. As of fall 1992, 102,000 Medicaid recipients 
had been a part of the demonstration. An evaluation data base consisting of the 
Medicaid Client Assessment, Review, and Evaluation (CARE) claims documents for 
the 102,000 recipients with at least 3 assessments will be used for the evaluation of 
the demonstration. The final report will be submitted in summer 1993. 

Medicare waivers were approved and the Medicare pilot test is scheduled for im- 
plementation in the four Austin area nursing homes in November 1992 for a period 
of 15 months. At the time of their 1991 federal certification survey, the pilot test 
facilities had 59 Medicare Part A covered residents. Cost analyses of both national 
and State samples of Medicare providers were performed to arrive at baseline costs 
for calculating the rates for the RUG-T18 groups. The modified patient assessment 
instrument, the MDS plus, that was developed for the multistate Nursing Home 
Case-Mix and Quality (NHCMQ) demonstration will be used for Medicare classifica- 
tion. In the Medicare pilot, a nurse will review new admissions weekly onsite to 
classify residents into the RUG-T18 groups and to give prior authorization of the 
Medicare stays for specific time intervals. The interrater reliability of the project 
nurse and the facility nurses will be documented. The lessons learned from this 
pilot will be used in the implementation of the NHCMQ demonstration. 

On Lok 's Risk-Based Community Care Organization for Dependent Adults 
Project Nos.: 95-P-98246/9; ll-P-98334/9. 
Period: November 1983-Indefmite. 
Award: Grants. 

Grantees: On Lok Senior Health Services, 1441 Powell Street, San Francisco, CA 
94133. California Department of Health Services, 714-744 P Street, Sacramento, CA 
95814. 

Investigator: Marie Louise Ansak. 

As mandated by Sections 603(c) (1) and (2) of Public Law 98-21, the Health Care 
Financing Administration granted Medicare waivers to On Lok Senior Health Serv- 
ices and Medicaid waivers to the California Department of Health Services. Togeth- 
er, these waivers permitted On Lok to implement an at-risk, capitated payment 
demonstration in which more than 300 frail elderly persons, certified by the Califor- 
nia Department of Health Services for institutionalization in a skilled nursing facili- 
ty, are provided a comprehensive array of health and health-related services in the 
community. The current demonstration maintains On Lok's comprehensive commu- 
nity-based program but has modified its financial base and reimbursement mecha- 
nism. All services are paid for by a predetermined capitated rate from both Medi- 
care and Medicaid (Medi-Cal). The Medicare rate is based on the average per capita 
cost for the San Francisco County Medicare population. The Medi-Cal rate is based 



64 



on the State's computation of current costs for similar Medi-Cal recipients, using 
the formula for prepaid health plans. Individual participants may be required to 
make copayments, spend down income, or divest assets, based on their financial 
status and eligibility for either or both programs. On Lok has accepted total risk 
beyond the capitated rates of both Medicare and Medi-Cal with the exception of the 
Medicare payment for end stage renal disease. The demonstration provides service 
funding only under the waivers. The research and development activities are funded 
through private foundations. 

Section 9220 of Public Law 99-272 has extended On Lok's Risk-Based Community 
Care Organization for Dependent Adults indefinitely, subject to the terms and con- 
ditions in effect as of July 1, 1985, except that requirements relating to data collec- 
tion and evaluation do not apply. 

Quality of Care in the Program for All-inclusive Care for the Elderly Model 
Period: August 1991-July 1992. 
Funding: $60,117. 

Awardee: University of Minnesota Research Center. 
Investigator: Robert Kane, M.D. 

The purpose of this study is to develop measures to assess quality of care on both 
a routine and periodic basis in the Program for All-Inclusive Care for the Elderly 
(PACE) model of care. These measures may be used in PACE site quality assurance 
programs and quality assurance monitoring undertaken by the Health Care Financ- 
ing Administration and State Medicaid agencies. Attention will be given to meas- 
ures that reflect concerns relevant to both acute and long-term care and the provi- 
sion of that care in an integrated, capitated system. 

A series of meetings has been held with PACE site clinicians and experts in geri- 
atric care to develop tracer conditions for the quality assurance program. Prelimi- 
nary findings were presented to the PACE Public Policy Forum in May 1992. A 
final report is due November 1992. 

Evaluation of the Program for All-Inclusive Care for the Elderly Demonstration 
Period: June 1991-February 1996. 
Funding: $4,486,514. 

Contractor: Abt Associates, Inc., 55 Wheeler Street, Cambridge, MA 02138-1168. 
Investigator: Larry Branch, Ph.D. 

The Program for All-Inclusive Care for the Elderly (PACE) demonstration repli- 
cates a unique model of managed-care service delivery for 300 very frail community- 
dwelling elderly, most of whom are dually eligible for Medicare and Medicaid cover- 
age and all of whom are assessed as being eligible for nursing home placement ac- 
cording to the standards established by participating States. The model of care in- 
cludes as core services the provision of adult day health care and multidisciplinary 
team case management through which access to and allocation of all health and 
long-term care services are arranged. This model is financed through prospective 
capitation of both Medicare and Medicaid payments to the provider. The purpose of 
the evaluation is to examine PACE sites before and after assumption of full finan- 
cial risk, with the purpose of determining whether the PACE model of care, as a 
replication of the On Lok Senior Health Services model of care, is cost effective rela- 
tive to the existant Medicare and Medicaid systems. Specific evaluation questions 
relate to the model of care and the effects of the model on participant utilization, 
expenditures, and outcomes. 

An initial round of site visits has been completed, and the evaluation design and 
data collection plan are being revised based on these site visits. 

Demand for Formal and Informal Home Care Among the Functionally Impaired El- 
derly in the Community 
Period: August 1991-December 1991. 
Funding: $16,000. 

Contractor: Fu Associates, 2300 Clarendon Boulevard, Suite 1400, Arlington, VA 
22201. 

Investigator: Judith Sangl. 

For this project, the contractor provided programming support for an analysis of 
the demand for home care. A market price was created from 1984 Medicare home 
health aide charges to proxy the price of formal unskilled home care (i.e., non-nurs- 
ing care) in a county area. These price proxies were merged with the county of resi- 
dence of functionally impaired elderly community respondents in the 1984 National 
Long-Term Care Survey for the analysis. 

An average home health aide visit charge in the county was calculated by divid- 
ing the total charges for home health aide visits by the total number of visits. There 



65 



were a total of 460 unique counties for the survey sample; 56 counties did not have 
Medicare home health aide claims for which imputations were done using claims 
from similar contiguous counties. The Medicare charge per visit ranged from $7 to 
$73, with a mean of $40 and a standard deviation of 11.3. Medicare charges were 
found to be highest in the West and lowest in the Northeast. The Medicare charges 
were not found to be statistically significant in either (1) the probability of use of 
paid unskilled home care, or (2) the days of paid unskilled care used, given that one 
is a user. 

The Development of Long-Term Care Reform Strategy for New York's Office of 
Mental Retardation and Developmental Disabilities 
Period: June 1988-December 1990. 
Funding: $115,581. 

Awardee: New York State Department of Social Services, Division of Medical As- 
sistance, 40 North Pearl Street, Albany, NY 12243. 
Investigator: Howard Gold. 

The New York Office of Mental Retardation and Developmental Disabilities is 
conducting a 2V2-year project to develop a comprehensive plan and waiver applica- 
tion that would reform the financing, regulation, and service delivery of the mental- 
ly retarded and developmentally disabled (MR/DD) system in three districts cover- 
ing eight New York counties. The State considers the demonstration as the first 
step toward statewide implementation. The objectives are to: 

Develop a financing system that will improve services to the MR/DD popula- 
tion by expanding the number and types of people to be served and the types of 
services to be provided. 
Change the manner in which quality of care is assured. 
Constrain growth in Federal expenditures for these services. 
Waivers would alter the Medicaid basis of payment, revise the State Medicaid 
plan requirements, change how Medicaid funds can be used, and implement revised 
quality assurance regulations. The demonstration will test an alternative financing 
approach that approximates recently formulated departmental policy directions as 
developed by the Department of Health and Human Services working group on in- 
termediate care facilities for the mentally retarded. The project represents a major 
test of reform in the delivery of services for persons who are developmentally dis- 
abled. 

Both national and State-level advisory panels have been convened and issue 
papers have been completed. The State submitted and received approval of a Medic- 
aid 2176 home and community-based care waiver to implement this project. The 
waiver program was implemented in fall 1991. A final report was received and ac- 
cepted in spring 1992. 

Cohort Analysis of Disabled Elderly 
Period: August 1988-November 1991. 
Funding: $89,986. 

Awardee: Brandeis University Research Center. 
Investigator: Christine Bishop, Ph.D. 

For this project, researchers apply event history analyses to nationally represent- 
ative data sources to derive estimates of the transitions between various health 
status categories and the duration within categories for different wage groups. 
These data sources include multiple years of National Health Interview Surveys, 
mortality records, National Long-Term Care Surveys, Longitudinal Study of Aging, 
and the National Nursing Home Surveys. Researchers will also estimate, based on 
the type and level of severity of morbidity and disability categories, the risks in- 
volved and the duration of specific types of acute and long-term care. 

A draft final report on the analyses is expected in fall 1991. 

Long-Term Care Studies (Section 207) 
Period: September 1989-September 1994. 
Funding: $3,790,000. 

Contractor: Health and Sciences Research Incorporated, 9300 Lee Highway, Fair- 
fax, V A 22031. 

Investigator: David Kennell, Ph.D. 

The purpose of this project is to conduct research related to the Health Care Fi- 
nancing Administration's Medicare and Medicaid programs in the area of long-term 
care (LTC) policy development. The contractor will focus primarily on four major 
areas: 

The financial characteristics of Medicare beneficiaries who receive or need 
LTC services. 



66 



How the Medicare beneficiaries' characteristics affect their utilization of in- 
stitutional and noninstitutional LTC services. 

How relatives of Medicare beneficiaries are affected financially and in other 
ways when beneficiaries require or receive LTC services. 

How the provision of LTC services may reduce expenditures for acute care 
health services. 

Analyses will use existing LTC and other survey data bases (e.g., the National 
Long-Term Care Surveys, the Longitudinal Study of Aging, the National Nursing 
Home Survey, the Survey of Income and Program Participation, and the National 
Medical Care Expenditure Survey). Medicare administrative records and other 
extant information will also be utilized. A number of focused analytic studies, policy 
reports, syntheses, and special studies are required under the contract. 

With the repeal of the Medicare Catastrophic Coverage Act of 1988, this project is 
no longer congressionally mandated. A large number of studies have been initiated, 
and several draft reports have been received. Current studies include: 

— Health Care Service Use and Expenditures of the Non-Institutionalized Popula- 
tion 

— An Examination of the Relation of Part A and Part B Medicare Expenditures 

— The Catastrophic Costs of Long Term Care 

— Analysis of Induced Demand for Long Term Care Services 

— Issues in Long Term Care Policy for the Disabled Elderly with Cognitive Im- 
pairment 

— Synthesis of Literature on Targeting to Reduce Hospital Use 
— Synthesis on Reimbursement Options for Medicaid and Medicare Nursing Home 
Stays 

— Elderly Wealth and Savings; Implications for Long Term Care 
— Synthesis of the Literature on Effectiveness of Special Assistive Devices in Man- 
aging Functional Impairment 
— Nursing Home Bed Supply: Synthesis of the Literature and State Initiatives 
— Synthesis of the Literature on Unmet Need for Long Term Care Services 
— Synthesis of the Literature on Financing and Delivery of Long Term Care for 

the Disabled Non-Elderly 
— Examining the Competing Demands and Extra Expense of Informal Care of the 
Disabled Elderly 

— Analysis of Nursing Home Payment with Current Beneficiary Survey (CBS) 
Data 

— Analysis of Informal and Formal Care 

— The Potential of Coordinated Care Targeted to Medicare Beneficiaries with 

Medicaid Coverage 
— Analysis of Non-Participation in the 2176 Program 

Analysis and Comparison of State Board and Care Regulations and Their Effect on 
the Quality of Care in Board and Care Homes 
Period: September 1991-September 1992. 
Funding: $200,000. 

Awardee: Office of the Assistant Secretary for Planning and Evaluation, Room 
410-E, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, 
DC 20201. 

Investigator: Catherine Hawes, Ph.D. 

The Health Care Financing Administration (HCFA) has transferred funds to the 
Office of the Assistant Secretary for Planning and Evaluation (ASPE) in support of 
an existing contract with the Research Triangle Institute (RTI). ASPE has funded 
RTI to conduct a study to examine the relationship between the type and amount of. 
State regulation and the quality of care in board and care homes. In addition, the 
study will document the characteristics of a large sample of board and care homes, 
their residents, and owners /operators. HCFA's support will enable the contractor to 
increase the project's sample size to allow for analysis of the relationship between 
additional characteristics of board and care homes and to conduct a more detailed 
field test. 

The following ten states have been selected to participate in the study: New 
Jersey, Texas, Oklahoma, Georgia, Kentucky s Arkansas, Florida, Illinois, California, 
and Oregon. Survey instruments are currently under revision and pre-test activities 
are underway in facilities in North Carolina and the District of Columbia. Data col- 
lection activities are expected to begin in the fall of 1992. 

Financial Impact to Beneficiaries of Nursing Home Care 
Period: August 1988-August 1990. 
Funding: $129,888. 



67 



Awardee: Brandeis University Research Center. 
Investigator: Korbin Liu, Sc.D. 

For this project, researchers used The Urban Institute's Transfer Income Model-2 
(TRIM-2) for State estimates and the Connecticut Nursing Home Inventory data 
base to calculate nursing home use and payments. TRIM-2 is a microsimulation 
model based on the 1984 Current Population Survey used in forecasting use and 
payments. The Connecticut Inventory data base contains patient-specific informa- 
tion on all nursing home patients (private and public) from 1977 to the present. In 
addition, the 1985 National Nursing Home Survey was used to analyze several di- 
mensions of nursing home use. From the collected data, estimates for the nursing 
home patients' spend-down provision were made. 

A draft report, Changes in Duration and Outcomes of Nursing Home Stays: 1977- 
1985, was completed. The report concludes that changes have occurred in the overall 
composition of nursing home admissions from 1977 through 1985. The analysis indi- 
cates that nursing home patients have become older, more disabled, and more likely 
to have been admitted for terminal care. Once finalized, the report will be sent to 
the National Technical Information Service. An article was published in a journal: 
Liu, K., and Manton, K.: Nursing Home Length of Stay and Spend-down: Connecti- 
cut, 1977-1985. "Gerontologist" 31(2):165-173, 1991. This article reports data on 
nursing home stays over an 8-year period, October 1977 to September 1985. Person- 
specific records were merged with death certificates and Medicaid eligibility dates, 
and multiple stays for individuals were studied using life-table methodologies. One 
of the major study findings is the distribution of the length of nursing home stay 
based on person-level use (multiple stays rather than single stays are markedly dif- 
ferent). For example, Connecticut's data based on person-level use indicate that 39 
percent of an admission cohort are still residents at 2 years compared with only 16 
percent based on single stays. This information has important implications for 
design of private insurance policies or public policy options. Another major finding 
is that approximately 21 percent of individuals not covered by Medicaid who enter 
nursing homes ultimately convert to Medicaid. The timing of spend-down was over 1 
year for one-half of the individuals, which is longer than indicated by some other 
studies. A final major finding is that the estimate of the proportion of Medicaid to 
total nursing home days is 55.3 percent. However, Medicaid's proportion to the cost 
of care is expected to be less because of the contribution from income of persons 
spending down. 

Use of Medicare Part A and Part B in Nursing Homes 
Period: August 1991-December 1992. 
Funding: $100,000. 

Awardee: Brandeis University Research Center. 
Investigator: Korbin Liu, Sc.D. 

For this project, researchers will examine the relationship between Medicare Part 
A and Part B service use in nursing homes. This includes examining: 

The extent to which Part B therapy services are used for patients with a fully 
or partially covered Part A skilled nursing facility stay. 
The patterns of physician visits to nursing homes. 

The overall Medicare Parts A and B costs incurred in the nursing home by 
Part A-covered patients. 
Data analysis is underway and the final report is expected in December 1992. 

Changes in Post-Hospital Care Utilization Among Medicare Patients 
Period: August 1989-December 1992. 
Funding: $102,247. 

Awardee: The RAND Policy Research Center. 
Investigator: Richard Neu, Ph.D. 

For this project, a data file was created linking Medicare billing records for inpa- 
tient hospital and post-hospital care for 1987 and 1988. RAND is using this file to 
document changes in post-hospital utilization among Medicare patients. The analy- 
ses will include an examination of skilled nursing facility, home health agency, and 
rehabilitative hospital care. 

Reanalyses with revised HCFA data were required due to the discovery of a large 
number of missing home health claims. A final report of the findings is expected in 
December 1992. 

Analysis of Implementation Issues Related to a Capitated Acute and Long-Term Care 
Service Delivery System 
Period: August 1991-1992. 
Total Funding: $99,822. 



68 



Awardee: Brandeis University Research Center. 
Investigator: Walter Leutz, Ph.D. 

The purpose of this project is to analyze issues related to marketing strategies, 
reimbursement rates and mechanisms, site selection criteria, and site operational 
protocols for a capitated acute and long-term care service delivery system. 

This project is in the early developmental stage. 

New York State Quality Assurance System Evaluation 
Period: October 1989-December 1992. 
Funding: $349,477. 

Contractor: Abt Associates, Inc., 55 Wheeler Street, Cambridge, MA 02138-1168. 
Investigator: Margot Cella. 

The objectives of the New York State Quality Assurance System (NYQAS) are to 
link data from the case-mix reimbursement system for use in the quality assurance 
system and to integrate the quality assurance processes of survey and certification, 
inspection of care, and utilization review. The purpose of the evaluation is to deter- 
mine which aspects of NYQAS are effective and which are not, and why. Research- 
ers hope that this information will improve the implementation and monitoring of 
The Multistate Nursing Home Case-Mix and Quality Demonstration, the nursing 
home reform provisions of the Omnibus Budget Reconciliation Act of 1987, and the 
surveillance of nursing homes in general. Consistent with these objectives, the eval- 
uation will employ a variety of qualitative and quantitative methods to assess 
NYQAS' reliability and validity of problem identification, monitoring, and enforce- 
ment, and the impact of NYQAS on the quality of care. 

Several factors have delayed the implementation of this evaluation, including 
problems of access to the required data. The project has been extended to December 
1992. At this point, draft reports have been received on the influence of NYQAS on 
casemix, resident deterioration and adverse outcomes, and a case study on the valid- 
ity of the NYQAS survey process. 

The Multistate Nursing Home Case-Mix and Quality Demonstration 

Project Nos.: Kansas, ll-C-99366/7, Maine, ll-C-99363/1, Mississippi, 11-C- 
99362/4, South Dakota, ll-C-99367/8. 

Period: June 1989-June 1996. 

Funding: $2,098,831. 

Awardees: State Medicaid Agencies. 

This project builds on past and current initiatives with case-mix payment and 
quality assurance. The 6-year demonstration will design, implement, and evaluate a 
combined Medicare and Medicaid system in four States — Kansas, Maine, Mississip- 
pi, and South Dakota. The purpose of the demonstration is to test a resident infor- 
mation system with variables for classifying residents into homogeneous resource 
utilization groups for equitable payment and for quality monitoring of outcomes ad- 
justed for case mix. The new minimum data set plus (MDS+) for resident assess- 
ment will be used for resident care planning, payment classification, and quality 
monitoring systems. The project consists of three phases — systems development and 
design, systems implementation and monitoring, and evaluation. 

The project has conducted a field test of the minimum data set on 6,660 nursing 
home residents. The average direct-care staff time across the States is 115 minutes 
per day. A new patient classification system and a Medicare/Medicaid Payment 
Index (M 3 PI) containing 44 groups has been created. The States implemented the 
MDS+ in fall 1990 with the approval of the Health Standards and Quality Bureau. 
The States have collected and reviewed over 300,000 assessments on 100,000 differ- 
ent residents assessed between October, 1990 and July 1992. In preparation for de- 
veloping the payment systems for the demonstration, the resident characteristic 
data and facility cost reports are being analyzed to determine the case-mix of resi- 
dents and patterns of service utilization. The States expect to have their proposed 
payment system changes ready but early 1993. The demonstration States are sched- 
uled to implement the new Medicare and Medicaid payment systems and quality 
monitoring information systems in summer 1993. 

Long-Term Care Case-Mix and Quality Technical Design Project 
Period: September 1989-September 1993. 
Funding: $2,427,594. 

Contractor: The Circle, Inc., 8201 Greensboro Drive, Suite 600, McLean, VA 22102. 
Investigator: Robert Burke, Ph.D. 

This 4-year contract will support the design and early implementation phase of 
The Multistate Nursing Home Case-Mix and Quality (NHCMQ) Demonstration. The 
demonstration combines the Medicare and Medicaid nursing home payment and 



69 



quality monitoring system across several States — Kansas, Maine, Mississippi, New 
York, South Dakota and Texas. This project builds on past and current initiatives 
with nursing home case-mix payment and quality assurance in nursing homes. The 
purpose of the demonstration is to test a resident information system with variables 
for classifying residents into homogeneous resource utilization groups for equitable 
payment and for quality monitoring of process and outcomes adjusted for case mix. 
The project will have three phases: 

Systems design and development. 

Systems implementation and monitoring. 

Evaluation. 

The classification system to be used across the demonstration States for Medicare 
and Medicaid was completed in June 1991 by researchers from The University of 
Michigan and Rensselaer Polytechnic Institute. The resource utilization groups, ver- 
sion III (RUG-III) uses 44 groups to explain approximately 45 percent of the vari- 
ance in nursing staff time and 52 percent of the costs across nursing, occupational 
therapy, physical therapy, speech pathology, transportation, and social work serv- 
ices. The RUG-III groups are split on clinical conditions including signs and symp- 
toms of distress, type and intensity of service, and activities of daily living. The 27 
groups at the top of the classification match the Medicare coverage criteria. A work- 
ing paper entitled Description of the Resource Utilization Group, Version III (RUG- 
III), which describes the classification, has been developed. The common assessment 
tool, the minimum data set plus (MDS+), has been published and implemented as 
the State resident assessment instrument in the demonstration States: Feldman, J., 
and Boulter, C, eds.: "Minimum Data Set Plus (MDS+). Multistate Nursing Home 
Case Mix and Quality Demonstration Training Manual." Natick, MA. Eliot Press, 
1991. 

During the past year, a coordinated effort has been undertaken to develop the 
state specific Medicaid payment systems and the Medicare payment system using 
cost reports from 1990. The analysis of 1990 Medicare cost reports and 1991 case-mix 
data to develop the Medicare payment design is well underway. The Medicare Pay- 
ment Workgroup has met once and continuing input is being received from profes- 
sional associations and the nursing home industry. The payment design should be 
completed by early spring 1993. The University of Wisconsin researchers developed 
and analyzed 158 quality indicators (QIs) which will be reviewed by expert surveyors 
from the six States, a research oriented quality panel, and a clinical workgroup of 
60 health professionals representing about 15 disciplines working in long-term care. 
The final set of QIs will serve to enhance the quality assurance process to be used 
for the operational phase of the demonstration. The demonstration is expected to 
become operational in summer 1993. 

Impact of Omnibus Budget Reconciliation Act Drug Regulations: Nursing Home 
Trends in Rates of Drug Use 
Period: August 1991-January 1993. 
Funding: $25,000. 

Awardee: University of Minnesota Research Center. 
Investigator: Judith Gerrard, Ph.D. 

The purpose of this project is to study the impact of the first year of the Omnibus 
Budget Reconciliation Act (OBRA) of 1987 on the use of psychotropic drugs in Min- 
nesota nursing homes. An analysis of trends in rates of psychotropic drugs before 
and after the implementation of the OBRA Drug Regulations will focus on: 

The use of antipsychotic drugs. 

The use of antianxiety drugs. 

The use of antidepressant drugs. 

The rates of appropriate and inappropriate use of antipsychotic drugs. 

"Appropriate use" of antipsychotic drugs is defined as the presence of a HCFA- 
specified diagnosis when an antipsychotic drug is used. All rates are adjusted for 
nursing home case-mix. Data for this statistical analysis are the patient information 
in the case-mix reimbursement system, a secondary source data base from the Min- 
nesota Department of Health. 

A draft final report has been received and is under reviewed. 

Evaluation of Life-Continuum of Care Residential Centers in the United States 
Period: January 1985-September 1989. " 
Funding: $832,871. 

Awardee: Hebrew Rehabilitation Center for the Aged, 1200 Centre Street, Boston, 
MA 02131. 
Investigator: Sylvia Sherwood, Ph.D. 



70 



The objective of this project was to obtain information about the characteristics of 
continuum of care residential centers (CCRCs) and their residents and to compare 
these characteristics with respect to quality of life and health, service costs, and uti- 
lization with those of elderly residents living in the community. Data were gathered 
from 20 CCRCs in Arizona, California, Florida, and Pennsylvania. These sites were 
stratified according to the type of contract offered (extended versus limited), the age 
of the facility, and the income levels of those enrolled. Three types of CCRC resi- 
dents were selected from the sites for the study sample — new admissions (580), exist- 
ing residents, both short- and long-stay residents (1,640), and residents who died just 
prior to or during the field data gathering period (660). Quality of life and service 
utilization data were gathered at two points in time, at baseline and 12 months 
later. Three types of comparison samples were employed: 

A representative sample of elderly in their own homes or independent apart- 
ments (2,422). 

A national sample of elderly living in congregate housing settings (2,350). 
A representative sample of elderly who have died and for whom retrospective 
data are available for their last year of life (1,500). 
A draft final report has been received and is under review. Once accepted, the 
report will be made available through NTIS. 

Study of Adult Daycare Services 
Period: June 1989-January 1990. 
Funding: $96,950. 

Contractor: Institute for Health and Aging, University of California, San Francis- 
co, 201 Filbert Street, San Francisco, CA 94133. 
Investigator: Rick Zawadski, Ph.D. 

The purpose of this survey of adult day centers was to provide updated informa- 
tion on: 

Who the adult day centers serve. 

The number of centers and their locations. 

The services the centers provide. 

The characteristics of operating these centers. 

Who funds these centers. 

The cost of operating these centers. 

Licensing, certification, and quality assurance standards governing these 
centers. 

How these characteristics vary by State. 
Funding for the survey was obtained from the American Association for Retired 
Persons. All the known and designated adult day centers in the United States (over 
2,100) were mailed a survey during February 1989. Responses were received from 
1,425 centers in 49 States providing information on organizational structure, licens- 
ing and certification, client characteristics, operating time and attendance, services 
provided, staffing, program costs, and revenue. A contract was awarded to the Uni- 
versity of California, San Francisco, to perform the analyses of the survey data. The 
contractor found that most centers are nonprofit organizations. The service package 
available in adult day centers varies, but most centers include recreational therapy; 
meals and transportation; social work; nursing; personal care; and medical assess- 
ment. Clients are predominantly older persons who are physically and/ or cognitive- 
ly impaired. The average program enrollment was 37 and daily attendance was 
fewer than 20. The daily operating cost in 1989 was $36, with more than one-half of 
the centers operating at a deficit. Medicaid was the largest funding source of adult 
daycare. A draft final report on the analysis has been received and is being revised. 
The final report is expected to be available by the end of 1992. With the repeal of 
the Medicare Catastrophic Coverage Act of 1988, this project is no longer congres- 
sionally mandated. 

Program for All-inclusive Care for the Elderly (On Lok) Case Study 
Period: August 1989-June 1991. 
Funding: $172,138. 
Award: Cooperative Agreement. 
Awardee: University of Minnesota Research Center. 
Investigator: Robert Kane, M.D. 

For this study, researchers will provide a descriptive analysis of the early stages 
of the Program for All-inclusive Care for the Elderly (PACE) demonstration. They 
will examine in detail the model of service delivery provided by On Lok Senior 
Health Services, San Francisco, California, and the degree to which aspects of this 
model are successfully replicated in eight sites nationwide. The results are expected 
to have utility as subsequent sites are developed for later implementation. 



71 



Two rounds of site visits to On Lok and PACE sites were completed and an inter- 
im report was submitted. A final report entitled Qualitative Analysis of the Pro- 
gram for All-inclusive Care for the Elderly (On Lok) Case Study has been sent to 
the National Technical Information Service, accession number PB92-1784091. In ad- 
dition to comparing eight PACE sites to On Lok on seven features of the PACE 
model, the researchers offer some lessons learned from the first eight sites regard- 
ing replicability; sources of start-up and development funds, census building, staff- 
ing, and patient mix of enrollees are seen as critical issues to future sites. Also 
offered are some issues to be faced by the evaluators, including the difficulty of se- 
lecting appropriate comparison groups, data equivalence across experimental and 
comparison groups, the need to collect additional data regarding enrollee outcomes 
(e.g., client and family satisfaction, affect, and quality of life), and statistical power 
and the role of pooling. The following article has been published: 

Kane, R., Hixon Illston, L., and Miller, N.: Qualitative analysis of the Program of 
All-inclusive Care for the Elderly (PACE). "The Gerontologist," forthcoming. 

Frail Elderly Demonstration: The Program for All-inclusive Care for the Elderly 
Period: June 1990-October 1994. 
Grantees: See Below. 

As mandated by Public Law 99-509, as amended, the Health Care Financing Ad- 
ministration will conduct a demonstration which replicates, in not more than 15 
sites, the model of care developed by On Lok Senior Health Services in San Francis- 
co, California. The Program for All-Inclusive Care for the Elderly (PACE) demon- 
stration replicates a unique model of managed-care service delivery for 300 very 
frail community-dwelling elderly, most of whom are dually eligible for Medicare and 
Medicaid coverage and all of whom are assessed as being eligible for nursing home 
placement according to the standards established by participating States. The model 
of care includes as core services the provision of adult day health care and multidis- 
ciplinary case management through which access to and allocation of all health and 
long-term care services are arranged. Physician, therapeutic, ancillary, and social 
support services are provided onsite at the adult day health center whenever possi- 
ble. Hospital, nursing home, home health, and other specialized services are provid- 
ed extramurally. Transportation is also provided to all enrolled members who re- 
quire it. This model is financed through prospective capitation of both Medicare and 
Medicaid payments to the provider. Demonstration sites are to assume financial risk 
progressively over 3 years, as stipulated in the Omnibus Budget Reconciliation Act 
of 1987. The eight sites and their State Medicaid agencies that have been granted 
waiver approval to provide services are: 

Elder Service Plan 

Period: October 1989-May 1993. 

Grantee: East Boston Geriatric Services, Inc., 10 Gove Street, East Boston, MA 
02128. 

Period: October 1989-May 1993. 

Grantee: Massachusetts State Department of Public Welfare, 180 Tremont Street, 
Boston, MA 02111. 

Providence ElderPlace 

Period: October 1989-May 1993. 

Grantee: Providence Medical Center, 4805 Northeast Glisan Street, Portland, OR 
97213. 

Period: October 1989-May 1993. 

Grantee: Oregon State Department of Human Resources, 313 Public Service 
Building, Salem, OR 97310. 

Comprehensive Care Management 
Period: October 1989-August 1993. 

Grantee: Beth Abraham Hospital, 612 Allerton Avenue, Bronx, NY 10467. 
Period: October 1989-August 1993. 

Grantee: New York State Department of Social Services, 40 North Pearl Street, 
Albany, NY 12243. 

Palmetto SeniorCare 

Period: August 1990-September 1993. 

Grantee: Richland Memorial Hospital, Five Richland Medical Park, Columbia, SC 
29203. 

Period: August 1990-September 1993. 




72 



Grantee: South Carolina State Health and Human Services, Finance Commission, 
P.O. Box 8206, Columbia, SC 29202. 

Community Care for the Elderly 
Period: August 1990-October 1993. 

Grantee: Community Care Organization of Milwaukee County, Inc., 1845 North 
Farwell Avenue, Milwaukee, WI 53202. 
Period: August 1990-October 1993. 

Grantee: Wisconsin State Department of Health and Social Services, P.O. Box 
7850, Madison, WI 53707. 

Total Longterm Care, Inc. 
Period: August 1991-July 1994. 

Grantee: Total Longterm Care, Inc., 1801 East 19th Avenue, Denver, CO 80218. 
Period: August 1991-July 1994. 

Grantee: Colorado Department of Social Services, 1575 Sherman Street, Denver, 
CO 80203. 

Bienvivir Senior Health Services 

Period: December 1991-January 1995. 

Grantee: Bienvivir Senior Health Services, 6000 Welch, Suite A-2, El Paso, TX 
79905. 

Period: December 1991-January 1995. 

Grantee: Texas Department of Human Services, 701 West 51st Street, Austin, TX 
78714. 

Independent Living for Seniors 
Period: March 1992-April 1995. 

Grantee: Rochester General Hospital, 1425 Portland Avenue, Rochester, NY 
14621. 

Period: March 1992-April 1995. 

Grantee: New York Department of Social Services, 40 North Pearl Street, Albany, 
NY 12243. 

Up to seven additional sites may be phased in over the next 2 years. A contract to 
evaluate the PACE demonstration was awarded in June 1991. Presentations of the 
demonstration implementation and evaluation issues were given at the following 
national meetings: American Public Health Association annual meeting and Geron- 
tological Society of America annual meeting. 

Policy Study of the Cost Effectiveness of Institutional Subacute Care Alternatives 
and Services: 198J>-92 
Period: May 1990-April 1994. 
Funding: $1,370,000. 

Awardee: University of Colorado, Health Sciences Center, 4200 East 9th Avenue, 
Box C-241, Denver, CO 80262. 

Investigator: Andrew Kramer, M.D. 

The University of Colorado will assess which subacute institutional settings and 
combinations of services are most cost effective and provide more positive outcomes 
for various types of patients. Researchers will identify potential Health Care Fi- 
nancing Administration (HCFA) policy changes that might encourage use of the 
most appropriate settings and services. This 4-year project will use primary and sec- 
ondary data from three previous HCFA-sponsored studies to compare quality, cost 
effectiveness, case mix, service mix, and utilization among institutional subacute 
care alternatives (e.g., skilled nursing facilities and rehabilitation hospitals) within 
and between two time periods — 1984-87 and 1990-92. This methodology is designed 
to determine the most cost-effective combinations of services and provider settings 
for various types of patients requiring subacute care; i.e., stroke and hip fracture. 

Cross-sectional and longitudinal data collection started in October 1991. As of July 
1992, 116 facilities were recruited and 73 had been visited. 

Long-Term Care Survey 

Period: September 1990-February 1993. 
Award: Interagency Agreement. 

Agency: National Institute on Aging, 9000 Rockville Pike, Bethesda, MD 20892. 

The Office of the Assistant Secretary for Planning and Evaluation and the Health 
Care Financing Administration agree to transfer funds to the National Institute on 
Aging (NIA) to support an existing NIA grant to Duke University, Center for Demo- 
graphic Studies. This grant, number 1R37AG07198, is entitled Functional and 
Health Changes pf the Elderly, 1982-89. The National Long-Term Care Survey 



73 



i (NLTCS) is a detailed household survey of persons 65 years of age or over who have 
j some chronic (90 days or more) functional impairment. The survey has been admin- 
' istered three times. The first, conducted in 1982, was devised as a cross-sectional 
I survey. The second, conducted in 1984, added a longitudinal component to the 
I sample design. The third, administered in 1989, used the cohorts from the previous 
surveys in addition to persons becoming 65 years of age to form a nationally repre- 
sentative sample of impaired elderly persons. To facilitate the use of the data base, 
the following tasks related to the 1982, 1984, and 1989 NLTCSs will be carried out 
under this agreement: 

File linkage over the entire period 1982-89. 
Derivation of new longitudinal sample weights. 
Linkage of Medicare administrative records. 
Improvement of coding by checking consistency of survey items. 
Improvement in survey documentation. 
5 Seminars and education. 

Weights for the 1982 and 1984 surveys have been revised and a file with Medicare 
j Part B records has been prepared. File cleanup and documentation improvement for 
! the 1982, 1984 and 1989 NLTCS are proceeding. Additional Medicare records have 
just been received to complete the time period covered by all three waves of the 
survey. 

j Long-Term Care: Elderly Service Use and Trends 

Period: August 1989-June 1991. 
I Funding: $245,249. 

J Awardee: The Brookings Institution, 175 Massachusetts Avenue, NW., Washing- 
I ton, DC 20036-2188. 

Investigator: Joshua Wiener, Ph.D. 
This project has three objectives: 

An analysis of the financial status of nursing home users. 
An analysis of the determinants of home care use. 

Projections of the numbers and level of disability among the elderly and their 
use of long-term care services. 

Data from the following major surveys will be used — the 1982 and 1984 National 
Long-Term Care Surveys, the 1984-86 Supplement on Aging/ Longitudinal Study of 
Aging, and the 1984 Survey of Income and Program Participation. Data will be ana- 
lyzed using cross-tabulations, logistic and least squares regression analyses, and the 
Brookings/Intermediate Care Facility simulation model (updated and revised). 

Two journal articles have been published presenting some of the study findings. 
The first article, "Use of Paid Home Care by the Chronically Disabled Elderly," 
"Research on Aging," 13(3): 310-332, examined the determinants of home care use. 
Using logistic regression, the analysis found the predictors of any use of paid home 
care were age, sex, marital status, number of daughters and sons, ADL problems, a 
prior nursing home stay, an overnight hospital stay, income, home equity, and Med- 
icaid enrollment. Using ordinary least squares regression, the study also identified 
predictors of the amount of formal homecare used in the past week. For elderly 
with a paid home care provider, greater age, disability level, not being married, 
fewer daughters, and cognitive impairment signal significantly more use. 

The second article, "Will Paid Home Care Erode Informal Support?" in "Journal 
of Health Politics, Policy and Law" 16(3):507-521, examined whether the amount of 
paid home care used by disabled elderly persons had a significant influence on the 
amount of informal support they were receiving. Results from a two-stage least 
squares regression analysis suggest that the amount of informal home care received 
was not significantly affected by the level of formal care. This conclusion held for 
subgroups of formal care users most likely to exhibit substitution: those without cog- 
nitive problems, the disabled elderly with above average income, and persons who 
lived alone. Even the most severely disabled elderly, who are the target of most pro- 
posals to expand paid home care, did not substitute paid care for unpaid. 

A draft final report for the entire project is expected by the end of 1992. After 
review, the report wi]l be available through NTIS. 

Study of Alternative Out-of-Home Services for Respite Care 
Period: September 1988-February 1990. 
Funding: $239,495. 

Awardee: Brandeis University Research Center. 
Investigator: Christine Bishop, Ph.D. 

For this study, Brandeis examined the advisability of expanding the respite care 
benefit to cover out-of-home services such as those provided in a nursing home or an 
adult day care center as an alternative to in-home respite care. Researchers as- 



74 



sessed the advisability of broadening the respite care benefit to include alternative 
services, giving consideration to cost, access, quality of care, and the feasibility of 
implementation. This assessment was accomplished by using information collected 
from existing data sets and from ongoing respite programs and demonstrations. 

The final report entitled Respite Care: Background and Use has been received and 
is under review. Researchers conclude that both in-home and out-of-home care 
should be considered in the designs of any new respite programs. The report should 
be available in late 1991. With the repeal of the Medicare Catastrophic Coverage 
Act of 1988, this project is no longer congressionally mandated. 

Categorization of Nursing Homes and Rehabilitation Facilities 
Period: August 1991-December 1992. 
Funding: $94,362. 

Awardee: University of Minnesota Research Center. 
Investigator: Robert Kane, M.D. 

Factors will be identified that differentiate the type and intensity of rehabilitative 
and other post-acute services provided to Medicare beneficiaries in nursing homes 
and rehabilitative facilities. Using these factors, a classification system will be de- 
veloped of post-acute institutional providers based on the amount of rehabilitative 
care they provide. The system will provide information on the extent of overlap in 
the provision of rehabilitative services by these facilities and relate the identified 
patterns of care to institutional characteristics. The feasibility of the classification 
system will be tested in a pilot project by using a sample of nominated rehabilita- 
tion facilities and nursing homes. The results of the pilot project will be used to pro- 
pose a study design for further refinements of the classification system and analysis 
of related issues. 

A sample of 168 nursing homes and rehabilitation facilities were nominated. Data 
analysis is underway and the final report is expected in December 1992. 

Implementing Federal Regulations in Nursing Homes: A Conceptual Paper 
Period: April 1990-December 1991. 
Funding: $52,630. 

Awardee: University of Minnesota Research Center. 
Investigator: Judy Gerrard, Ph.D. 

The purpose of this project is to develop a conceptual paper on the issues involved 
in regulating the use of psychoactive drugs in nursing homes, the range of problems 
that the long-term care (LTC) community and Health Care Financing Administra- 
tion (HCFA) surveyors might face in implementing these regulations, the quality of 
large-scale data bases available for examining these issues and problems, and the 
research designs that would be most appropriate for studying the impact of HCFA 
guidelines on the use of psychoactive drugs by nursing home elderly. Two panels of 
experts — a practitioner advisory panel consisting of five local practitioners in the 
LTC community and a national expert panel of researchers experienced in psy- 
choactive drug use by nursing home elderly — will be used in this project. 

This project is completed, and a final report has been accepted. 

Interaction of Medicaid and Private Long-Term Care Insurance 
Period: August 1991-December 1992. 
Funding: $80,000. 

Awardee: Brandeis University Research Center. 
Investigator: Christine Bishop, Ph.D. 

For this study, researchers will examine the characteristics of purchasers and 
nonpurchasers of private long-term care insurance, the types of insurance pur- 
chased, and the role of State Medicaid program characteristics and personal charac- 
teristics in influencing the purchase decision. 

State Medicaid program characteristics are being merged with the survey partici- 
pants. Data analysis is underway and the final report is expected in December 1992. 

Goals and Strategies for Financing Long-Term Care 
Period: August 1989- June 1991. 
Funding: $95,409. 

Awardee: University of Minnesota Research Center. 
Investigator: Mark Pauly, Ph.D. 

The purpose of this project is to use concepts drawn from a number of disci- 
plines — economics, decision sciences, policy analysis, sociology, and demography — to 
develop statements of possible objectives for long-term care insurance. Defining ob- 
jectives will include an analysis of benefits and costs from potential changes in fi- 
nancing and all analysis of expected behavioral changes in response to changes in 



75 



financing. The meaning of these objectives will then be illustrated by applying them 
to several types of policy proposals: 

Subsidization of private insurance. 

Employer-provided insurance. 

Whole-life versions of insurance. 

Means-tested public insurance. 

Medicaid-equivalent subsidies. 

Catastrophic public insurance. 

Public provision of information on Medicare coverage and the need for insur- 
ance. 

A final report was received in October 1991, and is available from the National 
Technical Information Service, accession number PB92-178383. The authors recom- 
mend that public policies should be designed to remove informational impediments 
to the emergence of long-term care insurance markets and to provide information 
about new services and assist in introducing these services to the market. Applica- 
tion of identified objectives to public service financing and/ or delivery of long-term 
care services raises several points, including the belief that provision of universal 
insurance for long term-care is not supported by the analysis and that a means- 
tested program will continue to be necessary, as private markets are insufficient to 
finance and deliver long-term care services. Several areas for future research are 
also identified, including methods to control moral hazard and more extensive test- 
ing of managed care systems for the elderly. 

Activities of Daily Living Measurements as Determinants of Eligibility 
Period: August 1989-October 1990. 
Funding: $99,991. 

Awardee: Brandeis University Research Center. 
Investigator: John Capitman, Ph.D. and Korbin Liu, Sc.D. 

For this study, researchers will use data from the National Long-Term Care Sur- 
veys, the National Long-Term Care Channeling Demonstration, and the Social 
Health Maintenance Organization Demonstrations' comprehensive assessment form 
to examine issues associated with defining and measuring activities of daily living 
(ADD for use as eligibility criteria for Medicare services. A cost analysis will be per- 
formed and other issues associated with using ADL scores as eligibility criteria will 
be discussed. Among the questions to be addressed are: 

What level of ADL impairments is used to trigger eligibility? 

Which ADL items should be used? 

Under what circumstances should assessments be performed and by whom? 
Three reports have been received. The first, The Administration of Eligibility for 
Community Long Term Care, considers issues and makes recommendations on eligi- 
bility criteria; timing and setting of assessments; assessment items; assessor qualifi- 
cations and training; and review and appeal procedures. The second, Home Care for 
the Disabled Elderly: Predictors and Expected Costs, uses a Tobit estimation proce- 
dure on data from the 1982 National Long-Term Care Survey. Major predictors of 
the number of paid in-home visits per week include age, sex, living arrangement, 
number of informal helpers, income, and functional status. Cognitive impairment 
was not found to be a significant predictor. The parameter estimates then were used 
to simulate the cost of providing home care services to select populations based on 
various combinations of program eligibility standards and the costs of some antici- 
pated behavioral responses to the institution of a home care program. The third, 
Predicting Participation and Costs in a National Long Term Care Program: Lessons 
from the Social HMO, explores what service utilization and costs might be like if 
there were a managed-care approach to long-term care and how utilization and cost 
would vary with different participant characteristics. Once finalized, these reports 
will be sent to the National Technical Information Service. 

Determinants of Home Care Costs 
Period: August 1990-January 1993. 
Funding: $125,140. 

Awardee: Brandeis University Research Center. 
Investigator: Korbin Liu, Sc.D. 

The original purpose of this project was to investigate the determinants of formal 
and informal home care and the mix of the two types of care. However, two short- 
comings in the data from Connecticut Community Care, Inc. (CCCI) for the study 
period preclude this: (1) prior to January 1991, only the services paid for by CCCI 
and not other sources (eg., Medicaid) were included; and (2) detailed information was 
not available for informal care. Instead, the study will investigate the patterns and 



76 



determinants of nursing home use in this community-based population. In addition, 
Medicaid spend-down among a community-based population will be analyzed. 
The data has been received and analyses are underway. 

Demand for Formal and Informal Home Care Among the Functionally Impaired El- 
derly in the Community — Part 2 
Funding: Intramural. 
Investigator: Judith A. Sangl. 

This study had two purposes: (1) to examine the effect of the price of formal (i.e., 
paid) home care, controlling for other factors, on the demand for formal home care 
among the functionally impaired elderly; and (2) to examine the effect of the price 
of formal home care, controlling for other factors, on the demand for informal (i.e., 
unpaid) home care among the functionally impaired elderly. For the purposes of this 
study, formal home care was defined as unskilled assistance, or help with non-nurs- 
ing tasks such as IADL and ADL tasks. The study sample was restricted to persons 
who are considered potentially price sensitive and in the current or potential pri- 
vate home care market. Persons who received formal home care paid solely by Med- 
icare and/or Medicaid are excluded because they face a zero price and the amount 
of home care is determined administratively, not by the individual. 

The study is cross-sectional with the elderly individual as the unit of analysis; 
county-level price proxies and other state policy and market factors are associated 
with the individual's county and state of residence. Individual-level data are from 
the 1984 National Long Term Care Survey. Market price proxies for formal home 
care at the county level are from two data sources: (1) 1984 Medicare home health 
aide charges; and (2) the 1980 Census service occupation wage data. Other state and 
market level data are obtained from a variety of other sources. Because of the small 
percentage of formal home care users, a 2-part model is used to examine (1) the 
probability of use; and (2) the amount of care used, given that one is a user. Multi- 
ple logistic regression was the statistical method used in the first part of the model; 
ordinary least squares regression was used in the second part of the model. Since 
almost all of the sample has informal care, a 2-part model is not necessary and ordi- 
nary least squares regression is used to analyze the days of care used. 

Three hypotheses were tested in the study: 

Hypothesis 1: The demand for formal home care is inversely related to its price. 

Hypothesis 2: Persons with greater functional impairment will be less responsive 
to price of formal home care than persons with less functional impairment. 

Hypothesis 3: The demand for informal home care will be directly related the 
price of formal home care. 

Preliminary results are available. With respect to the first hypothesis, the study 
found that there was a lower probability of use of paid unskilled home care by the 
elderly in counties where the service wages were higher. However, no relationship 
was found between price and the number of paid home care days used. With respect 
to the second hypothesis, no significant price-disability interactions were found for 
the probability of use of paid home care. With respect to the third hypothesis, price 
was not found to have a significant effect on unpaid care use or level of use. There 
are several important variables, other than price, which affect the demand for 
formal and informal home care. With respect to the probability of use of formal 
home care, elderly who were unmarried, older, female, white, and had higher 
income, more functional impairments, prior nursing home and hospital use, adult 
children who are working, and a non-relative household member all had a greater 
likelihood of using formal home care than persons without these characteristics. On 
the other hand, elderly who owned a home, had adult children living nearby, and 
had an adult child or female household members were less likely to use formal care. 
With respect to the number of formal home care days used, elderly who were un- 
married and older, had cognitive impairment, prior nursing home use, and received 
some payment subsidy used more days than elderly without these characteristics. 
The number of informal days was greater if the elderly person was married and 
black, and had hospital use, cognitive and more functional impairment, adult chil- 
dren nearby and relatives in the household. 

Validation of Nursing Home Quality Indicators 
Period: July 1992-July 1995. 
Funding: $790,945. 

Awardee: SysteMetrics/ McGraw-Hill, 104 West Anapamu Street, Santa Barbara, 
CA 93101. 

Investigator: David Klingman, Ph.D. 

This project is a continuation of a recently completed cooperative agreement to 
investigate the usefulness of claims data from Medicaid and Medicare administra- 



77 



tion record systems as sources of nursing home quality of care (QCIs) measures. The 
previous study involved retrospective analysis of 1987 Medicaid and Medicare claims 
data and facility deficiency data from two States. The goal of this project is to fur- 
ther the development of an automated quality assurance system using Medicare and 
Medicaid claims data to provide continuous monitoring of the quality of care ren- 
dered to Medicaid recipients in long term care facilities. The objective of this study 
is to validate the resident level claims-based QCIs by: (1) recomputation of the 
claims-based indicators for one State using data for 1990 and 1991 (i.e., pre and post 
OBRA 87), and an additional State for 1991; (2) physician and nurse examination of 
medical records for a sample of residents in a sample of nursing homes for the 
above States; and (3) establishment of the relationship of the QCIs to deficiencies 
cited and adverse outcomes. 
This project is in the early developmental stage. 

Long Term Care Program and Market Characteristics 
Period: February 1992-February 1993. 
Funding: $605,103. 

Awardee: University of California, San Francisco, Office of Research Affairs, 3333 
California Street, Suite 11, San Francisco, California 94143-0962. 
Investigator: Charlene Harrington, Ph.D. 

This project will collect data on and study the effects of nursing home and home 
health care characteristics and markets for Medicare and Medicaid services in fifty 
States. Primary and secondary data for the 1990-93 period will be collected to 
update earlier data collected in previous studies for the 1978-89 period. A compre- 
hensive survey will collect data on licensed nursing home bed supply and occupancy 
rates, State certificate-of-need programs, State preadmission screening programs, 
and Medicaid nursing home and home health reimbursement. A special analysis 
will provide detail on each States' current methodology for determining nursing 
home capital costs, the impact of proposed case-mix reimbursement on operating 
income, reimbursement methodology for free-standing sub-acute services/units, and 
Medicaid methodology used to reimburse for care in board and care homes, geriatric 
day care centers, and ICF-MR facilities. A public use database will be prepared to 
provide a complete set of data for the period 1978-1993. 

The project is in the early developmental stage. 

A Randomized Controlled Trial of Expanded Medical Care In Nursing Homes for 
Acute Care Episodes 
Period: March 1992-March 1995. 
Funding: $269,543. 

Awardee: Monroe County Long Term Care Program, Inc., 349 West Commercial 
Street, Suite 2250, East Rochester, NY 14445. 
Investigator: Gerald Eggert, Ph.D. 

The objective of this demonstration is develop, implement, and evaluate the effec- 
tiveness of expended medical services to nursing home residents who are undergoing 
acute illnesses, or deterioration in chronic ones, which would ordinarily require 
acute hospitalization. The intervention will include many services which are avail- 
able in acute hospitals and which are feasible and safe in nursing homes. These in- 
clude an initial physician visit, all necessary follow-up visits, diagnostic and thera- 
peutic services, and additional nursing care including private duty if necessary. The 
major goals of the demonstration are to reduce medical complications and disloca- 
tion trauma resulting from hospitalization, and to save the expense of hospital care 
when a patient could be managed safely in the nursing home with expanded serv- 
ices. 

This project is in the early development stages. 
Nurse Practitioner/Physician Assistant Aggregate Visit Demonstration 
Period: September 1990-September 1993. 
Funding: $130,538. 

Awardee: The Urban Medical Group, 545 D Centre Street, Jamaica Plain, MA 
02130. 

Investigator: Jeffery Kang, M.D. 

Under Section 6114(e) of Public Law 101-239, the Medicare program provides Part 
B coverage to nursing home residents for medical visits rendered by nurse practi- 
tioners who are members of a physician/physician assistant/ nurse practitioner 
team. Under this legislation, the number of visits supplied to any nursing home pa- 
tient is limited to an average of 1.5 visits per month. Section 6114(e) mandates a 
demonstration project under which the visit limitation would be applied on an aver- 
age basis over the aggregate total of residents receiving services from members of 



78 



the provider team. A preliminary Massachusetts demonstration project, Case Man- 
aged Medical Care for Nursing Home Patients, used nurse practitioners and physi- 
cian assistants to provide visits to nursing home patients. This demonstration ended 
on September 30, 1990. Many of the original Massachusetts demonstration sites are 
also participating in this second project. 

The project is being conducted in two phases. The first phase (primarily for plan- 
ning and development) was completed in March 1992. The second phase, which in- 
cludes the actual implementation and operation of the demonstration, began in 
April 1992. Negotiations with the Medicare carrier, Massachusetts Blue Cross and 
Blue Shield, are almost complete. The Urban Medical Group has arranged for ap- 
proximately 16 provider groups (medical teams) to participate in this demonstration. 
The final report for this project is expected in July 1993. 

Long-Term Care Supply and Medicare Hospital Utilization 
Period: August 1989-August 1990. 
Funding: $47,986. 

Awardee: Abt Associates, Inc., 55 Wheeler Street, Cambridge, MA 02138-1168. 
Investigator: Robert Schmitz, Ph.D. 

The purpose of this project was to investigate how local variations in the avail- 
ability of nursing home beds affect Medicare hospitalization rates. Effects on the 
number of admissions, the number of hospital readmissions, the number of hospital 
days used, and the costs per Medicare Part A enrollee were evaluated. Urban and 
rural differences were assessed. The impacts of community long-term care services, 
Medicare risk-contract health maintenance organization services, and the prospec- 
tive payment system on Medicare Part A utilization were evaluated. 

A final report was received in May 1992, and is being sent to the National Techni- 
cal Information Service. Findings from the report were presented at the Association 
for Health Services Research and American Public Health Association annual meet- 
ings. The author concludes that while increased availability of nursing home beds 
was found to reduce the average length of hospital stays, it also appeared to stimu- 
late rather than reduce hospital admissions for aged beneficiaries living in urban 
areas and to increase the likelihood of rehospitalization, contrary to the study's hy- 
potheses. Moreover, the increase in the probability of hospital admission associated 
with the addition of nursing home beds was most pronounced among the oldest 
beneficiaries, those most likely to use nursing home care. Furthermore, the relation 
between nursing home beds and hospital use was positive even after controlling for 
persistent county-specific effects. 

ADMINISTRATION FOR CHILDREN AND FAMILIES 

Title XX Social Service Block Grant Program 

The major source of Federal funding for social services programs in the States is 
Title XX of the Social Security Act, the Social Services Block Grant (SSBG) pro- 
gram. The Omnibus Budget Reconciliation Act of 1981 (P.L. 97-35) amended Title 
XX to establish the SSBG program under which formula grants are made directly to 
the 50 States, the District of Columbia, and the eligible jurisdictions (Puerto Rico, 
Guam, the Virgin Islands, American Samoa, and the Commonwealth of the North- 
ern Mariana Islands) for use in funding a variety of social services best suited to the 
needs of individuals and families residing within the State. Public Law 97-35 also 
permits States to transfer up to 10 percent of their block grant funds to other block 
grant programs for support of health services, health promotions and disease pre- 
vention activities, and low-income home energy assistance. 

Under the SSBG, Federal funds are available without a matching requirement. In 
fiscal year 1992, a total of $2.8 billion was allotted to States. The same amount has 
been appropriated for fiscal year 1993. Within the specific limitations in the law, 
each State has the flexibility to determine what services will be provided, who is 
eligible to receive services, and how funds are distributed among the various serv- 
ices within the State. State and/or local title XX agencies (i.e., county, city, regional 
offices) may provide these services directly or purchase them from qualified agencies 
-and individuals. 

A variety of social services directed at assisting aged persons to obtain or main- 
tain a maximum level of self-care and independence may be provided under the 
SSBG. Such services include, but are not limited to adult day care, adult foster care, 
protective services, health-related services, homemaker services, chore services, 
housing and home maintenance services, transportation, preparation and delivery of 
meals, senior centers, and other services that assist elderly persons to remain in 
their own homes or in community living situations. Services may also be offered 



79 



which facilitate admission for institutional care when other forms of care are not 
appropriate. Under the SSBG, States are not required to submit data that indicate 
the number of elderly recipients or the amount of expenditures provided to support 
specific services for the elderly. States are required, prior to the expenditures of 
funds under the SSBG, to prepare a report on the intended use of the funds includ- 
ing information on the type of activities to be supported and the categories or char- 
acteristics of individuals to be served. States also are required to report annually on 
activities carried out under the SSBG. Beginning with fiscal year 1989, the annual 
report must include specific information on the numbers of children and adults re- 
ceiving services, the amount spent in providing each service, the method by which 
services were provided, i.e., public or private agencies, and the criteria used in de- 
termining eligibility for each service. 

Based on an analysis of pre-expenditure reports submitted by the States for fiscal 
year 1991, the list below indicates the number of States providing certain types of 
services to the aged under the SSBG. 



Services: Number of States 1 

Home-Based Services 2 46 

Adult Protective Services 32 

Transportation Services 27 

Adult Day Care 28 

Health Related Services 30 

Information and Referral 27 

Home Delivered/Congregate Meals 22 

Adult Foster Care 11 

Housing 14 



1 Includes 50 States, the District of Columbia, and the 5 eligible territories and insular areas. 

2 Includes homemaker, chore, home health, companionship, and home maintenance services. 

In enabling the elderly to maintain independent living, most States provide 
Home-Based Services which frequently includes homemaker services, companion 
and /or chore services. Homemaker services may include assisting with food shop- 
ping, light housekeeping, and personal laundry. Companion services can be personal 
aid to, and/or supervision of aged persons who are unable to care for themselves 
without assistance. Chore services frequently involve performing home maintenance 
tasks and heavy housecleaning for the aged person who cannot perform these tasks. 

As reflected above, 32 States currently provide Adult Protective Services to per- 
sons generally 60 years of age and over. These services may consist of the identifica- 
tion, receipt, and investigation of complaints and reports of adult abuse. In addition, 
this service may involve providing counseling and assistance to stabilize a living ar- 
rangement. If appropriate, Adult Protective Services also may include the provision 
of, or arranging for, home based care, day care, meal service, legal assistance, and 
other activities to protect the elderly. 

Low Income Home Energy Assistance Program 

The Low Income Home Energy Assistance Program (LIHEAP) is one of six block 
grant programs administered within the Department of Health and Human Services 
(HHS). LIHEAP is administered by the Office of Community Services (OCS) in the 
Administration of Children and Families. 

LIHEAP helps low income households meet the cost of home energy. The program 
is authorized by the Omnibus Budget Reconciliation Act of 1981, as amended most 
recently by the Augustus F. Hawkins Human Services Reauthorization Act of 1990. 
In fiscal year 1989 Congress appropriated $1,383 billion for the program. Congress 
appropriated $1,443 billion for LIHEAP in fiscal year 1990. In fiscal year 1991, Con- 
gress appropriated $1,415 billion plus a contingency fund of $195 million, which 
went into effect when fuel oil prices went , above a certain level. For FY 1992, $1.5 
billion was appropriated, plus a contingency fund of $300 million that would have 
been triggered if the President had declared an emergency and had requested the 
funds from Congress. The FY 1993 HHS appropriations act provided funding of 
$1,346,049,760 for FY 1993. It also provided advance funding of $1,437,408,000 for a 
9-month transition period in FY 1994, of which $141,950,240 may be used by grant- 
ees to reimburse themselves for FY 1993 expenses. The transition period funds were 
provided in order to shift the LIHEAP program to a new "program year" of July 1 
to June 30. It is expected that the FY 1994 appropriations act will provide funds for 
the new program year of July 1, 1994 to June 30, 1995. 

Block grants are made to States, territories, and eligible applicant Indian Tribes. 
Grantees may provide heating assistance, cooling assistance, energy crisis interven- 



80 



tions, and low-cost residential weatherization or other energy-related home repair to 
eligible households. Grantees can make payments to households with incomes not 
exceeding the greater of 150 percent of the poverty level or 60 percent of the State's 
median income. 3 Most households in which one or more persons are receiving Aid to 
Families with Dependent Children, Supplemental Security Income, Food Stamps or 
need-tested veterans' benefits may be regarded as categorically eligible for LIHEAP. 

Low income elderly households are a major target group for energy assistance. 
They spend, on average, a greater portion of their income for heating costs than 
other low income households. Grantees are required to target outreach activities to 
elderly or handicapped households eligible for energy assistance. In their crisis 
intervention programs, grantees must provide physically infirm individuals the 
means to apply for assistance without leaving their homes, or the means to travel to 
sites where applications are accepted. 

In fiscal year 1992, about 37 percent of households receiving assistance with heat- 
ing costs included at least one person age 60 or over, as estimated by the March 

1992 Current Population Survey. 

OCS is a member of the National Energy and Aging Consortium, which focuses on 
helping older Americans cope with the impact of high energy costs and related 
energy concerns. 

No major program and policy changes for the elderly occurred in the 1990 reau- 
thorization legislation. No new initiatives commenced in 1992 or are planned for 

1993 that would impact on the status of older Americans. 

The Community Services Block Grant (CSBG) and the Elderly 

I. Community Service Block Grant — The Community Service Block Grant Act 
(Subtitle B, P. L. 97-35 as amended) is authorized through fiscal year 1994. The Act 
authorizes the Secretary, through the Office of Community Services (OCS), an office 
within the Administration for Children and Families in the Department of Health 
and Human Services, to make grants to States and Indian tribes or tribal organiza- 
tions. States and tribes have the authority and the flexibility to make decisions 
about the kinds of local projects to be supported by the State or tribe, using CSBG 
funds. The purposes of the CSBG program are: 

(A) to provide a range of services and activities having a measurable and po- 
tentially major impact on causes of poverty in the community or those areas of 
the community where poverty is a particularly acute problem; 

(B) to provide activities designed to assist low-income participants including 
the elderly poor — 

(i) to secure and retain meaningful employment; 

(ii) to attain an adequate education; 

(iii) to make better use of available income; 

(iv) to obtain and maintain adequate housing and a suitable living envi- 
ronment; 

(v) to obtain emergency assistance through loans or grants to meet imme- 
diate and urgent individual and family needs, including the need for health 
services, nutritious food, housing, and employment-related assistance; 

(vi) to remove obstacles and solve problems which block the achievement 
of self-sufficiency; 

(vii) to achieve greater participation in the affairs of the community; and 

(viii) to make more effective use of other programs related to the pur- 
poses of the subtitle, 

(C) to provide on an emergency basis for the provision of such supplies and 
services, nutritious foodstuffs and related services, as may be necessary to coun- 
teract conditions of starvation and malnutrition among the poor; 

(D) to coordinate and establish linkages between governmental and other 
social services programs to assure the effective delivery of such services to low- 
income individuals; and 

(E) to encourage the use of entities in the private sector of the community in 
efforts to ameliorate poverty in the community; (Reference Section 675(c)(1) of 
Public Law 97-35, as amended). 

It should be noted that although there is a specific reference to "elderly poor" in 
(B) above, there is no requirement that the States or tribes place emphasis on the 
elderly or set aside funds to be specifically targeted on the elderly. Neither the stat- 
ute nor implementing regulations include a requirement that grant recipients 



3 Beginning with fiscal year 1986, States are prohibited from setting income eligibility levels 
lower than 110 percent of the poverty level. 



81 



report on the kinds of activities paid for from CSBG funds or the types of indigent 
clients served. Hence, it is not possible for OCS to provide complete information on 
the amount of CSBG funds spent on the elderly, or the number of elderly, or the 
numbers of elderly persons served. 

II. Major Activities or Research Projects Related to Older Citizens in 1992 and 
1993 — The Office of Community Services made no major changes in program or 
policy related to the CSBG program in 1992 and none is planned for 1993. 

The Human Services Reauthorization Act of 1986 contained the following lan- 
guage: "each such evaluation shall include identifying the impact that assistance 
. . . has on . . . the elderly poor." 

The collection of impact data activity required by this language began in fiscal 
year 1991 and will be available in early 1993. 

III. Funding Levels — Funding levels under the CSBG program for States and 
Indian Tribes or tribal organizations amounted to $360 million in fiscal year 1992. . 
For fiscal year 1993, $372 million has been appropriated. 

Aging and Developmental Disabilities Program 

critical audiences project 

Grantee: Institute for the Study of Developmental Disabilities, Indiana University 
Project Director: Barbara Hawkins, Re. D., (812) 855-6506; Fax (812) 855-9630 
Project Period: 7/1/90-6/30/93, FY '90— $90,000, FY '91— $90,000, FY '92— 
$90,000, FY '93— $90,000 

The project provides training in a late-life functional-developmental model for au- 
diences that are critical to effective planning and care of older persons. Activities 
include developing training modules and instructional videos for interdisciplinary 
university credit courses, and illustrating the model by demonstration projects in 
community retirement settings. 

CENTER ON AGING AND DEVELOPMENTAL DISABILITIES (CADD) 

Grantee: University of Miami/CADD, Miami, FL 
Project Director: John Stokesberry, Ph.D., (305) 325-1043 

Project Period: 7/1/90-6/30/93, FY '90— $90,000, FY '91— $90,000, FY '92— 
$90,000, FY '93— $90,000 

CADD is providing education and training to service providers, parents and fami- 
lies; advocacy and outreach for consumers, information to the public on aging and 
developmental disabilities; networking, policy direction and community-based re- 
search. Materials will include a manual for parents/caregivers, a resource guide and 
a handbook on developing a peer companion project. 

INTERDISCIPLINARY TRAINING CENTER 

Grantee: UAP-Institute for Human Development, University of Missouri — Kansas 
City 

Project Director: Gerald J. Cohen, J.D., M.P.A., (816) 235-1770; Fax (816) 235-1762 
Project Period: 7/1/90-6/30/93, FY '90— $90,000, FY '91— $90,000, FY '92— 
$90,000, FY '93— $90,000 

The Center addresses personnel preparation needs with a focus on administration, 
interdisciplinary training, exemplary services, information/technical assistance/ re- 
search; and evaluation. Materials include training guide for aging, infusion models, 
inservice fellowship curriculum, resource bibliography, guide for training volun- 
teers, and course syllabus. 

TRAINING MODELS FOR RURAL AREAS 

Grantee: Montana University Affiliated Rural Institute on Disabilities, Missoula, 
MT 

Project Director: Philip Wittekiend, M.S. (406) 243-5467; Fax (406) 243-2349 
Project Period: 7/1/90-6/30/93, FY '90— $90,000, FY '91— $90,000, FY '92— 

$90,000, FY '93— $90,000 
Montana's focus is on linking existing networks and expertise to meet the unique 

needs of a rural area with sparse populations and limited professional resources. 

The project will develop audio conference packages with simultaneous long-distance 

training for remote areas and involve nontraditional networks such as churches and 

senior groups. 



82 



CONSORTIUM OF EDUCATIONAL RESOURCES 

Grantee: UAP-University of Rochester Medical Center, Rochester, NY 
Project Director: Jenny C. Overeynder, ACSW (716) 275-2986; Fax (716) 256-2009 
Project Period: 7/1/90-6/30/93, FY '90— $90,000, FY '91— $90,000, FY '92— 
$90,000, FY '93— $90,000 

An inter-university interdisciplinary consortium of educational resources in ger- 
ontology and developmental disabilities is being established in western New York, 
to be linked to local and State networks. The project will develop and implement 
preservice and inservice education curriculum for direct care and nursing home 
staff. 

AGING AND DEVELOPMENTAL DISABILITIES CLINICAL ASSESSMENT, TRAINING AND SERVICE 

Grantee: Waisman Center UAP, University of Wisconsin-Madison 
Project Director: Gary B. Seltzer, Ph.D., (608) 263-1472; Fax (608) 263-0529 
Project Period: 7/1/90-6/30/93, FY '90-$90,000, FY '91— $90,000, FY '92— $90,000, 
FY '93— $90,000 

Waisman Center operates an interdisciplinary clinic, provides training to health 
care and other professionals, and disseminates information and technical assistance 
to director care networks. Materials include a functional assessment instrument and 
curricula for medical students, geriatric fellows and physician assistants. 

INTERDISCIPLINARY TRAINING MODELS (IDT) 

Grantee: UAP, College of Family and Consumer and Consumer Sciences 
Project Director: Zolinda Stoneman, Ph.D., (404) 542-4872; Fax (404) 542-4815 
Project Period: 7/1/90-6/30/93, FY '91— $90,000, FY '92— $90,000, FY '93— $90,000 
This project is using IDT models for graduate and undergraduate training; devel- 
oping community-based internship and practicum sites; collecting audiovisual mate- 
rials for dissemination; and providing information to the UAP regional information 
and referral service. Products will include training videotapes and modules, course 
materials, and radio program recordings. 

COMMUNITY INTEGRATION PROJECT IN AGING AND DEVELOPMENTAL DISABILITIES 

(CIPADD) 

Grantee: NYS Office of Mental Retardation /DD, Albany, NY 

Project Director: Matthew P. Janicki, Ph.D. (518) 473-7855; Fax (518) 486-6714 

Project Period: FY '91— $147,255, FY '92— $147,255 

CIPADD is a cooperative effort of the New York State DD Planning Council, State 
Office for the Aging, State Office of Mental Retardation and DD, University of 
Rochester University Affiliated Program for Developmental Disabilities (UAPDD) 
Training Program in Aging and DD, Hunter College Brookdale Center on Aging, In- 
stitute of Gerontology at Utica College, and Rome DD Services Office. Products and 
activities include a how-to manual, case monographs on model projects, workshops 
demonstrating step-by-step approaches to promoting integration and a program 
manual. 

MISSOURI DEVELOPMENTAL DISABILITIES AND ELDERLY RESOURCE NETWORK (MODERN) 

Grantee: UAP-Institute for Human Development Missouri, MO Developmental 
Disabilities and Elderly Resource Network (MODERN) 
Project Director: Gerald J. Cohen, J.D., M.P.A. 
Project Period: FY '91— $142,160, FY '92— $142,160 

MODERN is a collaborative effort of the University of Missouri in Kansas City's 
Institute for Human Development through its Interdisciplinary Training Center on 
Gerontology and DD, Missouri Planning Council for DD, Missouri Protection and 
Advocacy Services, Missouri Division of Mental Retardation /DD, Missouri Associa- 
tion of County Developmental Disability Services, and local interagency groups from 
St. Louis, Clay/ Platte and Central Missouri. Products and activities include develop- 
ment of a centralized resource center with an 800 number, creation of an interagen- 
cy Task Force to address policy and procedural concerns, dissemination of models 
and strategies, cross-training of case managers, and support for local interagency 
work groups. 

PARTNERS II: IMPROVING SERVICES TO OLDER PERSONS WITH DD — POLICY TRAINING AND 

SERVICE 

Grantee: Virginia Institute for DD, Virginia Commonwealth University, Rich- 
mond, VA 



83 



Project Director: Joan Wood, Ph.D., (804) 786-8903; Fax (804) 371-7905 
Project Period: 7/1/90-6/30/93, FY '90— $90,000, FY '91— $90,000, FY '92— 
$90,000, FY '93— $90,000 

Project partners are Virginia Department of Aging, Board of Rights of Virginians 
with Disabilities, Virginia Center on Aging and Virginia Institute on DD at Virginia 
Commonwealth University, Rappahannock-Rapidan Community Services Center, 
Norfolk Senior Center, Virginia Department of Mental Health, Mental Retardation 
and Substance Abuse Services, SEVAMP Area Agency on Aging. Products and ac- 
tivities include recommendations for public policy, personnel training, staff ex- 
change, national teleconference, resource directories, community resource fairs, and 
strategies for identifying persons at risk for institutionalization. 

LIFE LONG PLANNING: DEVELOPING STATE AND LOCAL PLANNING LINKAGES TO IMPROVE 
OPPORTUNITIES FOR OLDER PERSONS WITH DEVELOPMENTAL DISABILITIES 

Grantee: Program on Aging and Developmental Disabilities, Madison, WI 
Project Director: Marilyn Wilson, (608) 263-0815 
Project Period: FY '90— $135,000, FY '91— $135,000, FY '92— $135,000 
A- cooperative effort of Bureau on Aging, Developmental Disabilities Office, Wais- 
man Center at the University of Wisconsin-Madison, Wisconsin Council on Develop- 
mental Disabilities, and the Wisconsin Coalition for Advocacy, the grant focuses on 
a rural and an urban county and on Wisconsin's older Native Americans who have 
developmental disabilities. Products and activities include a series of personal fu- 
tures planning and circles of support, local and statewide planning efforts, mono- 
graphs and articles for aging and developmental disability-related newsletter. 

INTERDISCIPLINARY TRAINING MODELS (IDT) 

Grantee: UAP, College of Family and Consumer and Consumer Sciences 
Project Director: Zolinda Stoneman, Ph.D., (404) 542-4827; Fax (404) 542-4815 
Project Period: 7/1/90-6/30/93, FY '90— $90,000, FY '91— $90,000, FY '92— 
$90,000, FY '93— $90,000 

This project is using IDT models for graduate and undergraduate training; devel- 
oping community-based internship and practicum sites; collecting audiovisual mate- 
rials for dissemination; and providing information to the UAP regional information 
and referral service. Products will include training videotapes and modules, course 
materials, and radio program recordings. 

ADMINISTRATION ON AGING— FY 1992 REPORT 

INTRODUCTION 

This report describes the major activities of the Administration on Aging (AoA) in 
Fiscal Year 1992. Title II of the Older Americans Act of 1965 (the Act) established 
the Administration on Aging (AoA) as the principal Federal agency for carrying out 
the provisions of the Act. The 1992 Amendments to the Act, which are described in 
Section I, reaffirm the responsibilities of AoA, State Agencies on Aging (SUAs), and 
Area Agencies on Aging (AAAs) to assure that provisions for serving older people 
are established, strengthened, and extended throughout the nation. Through the 
Amendments, Congress reaffirmed the need for strong partnerships with and on 
behalf of older people. Congressional action underscored concern for the most vul- 
nerable elderly and emphasized the need to assure that priority is given to strength- 
ening community level services on their behalf. 

The Older Americans Act seeks to remove barriers to economic and personal inde- 
pendence for older persons and to assure the availability of appropriate services for 
those older persons in the greatest social or economic need, with particular interest 
on those who are members of minority groups. The provisions of the Act are imple- 
mented primarily through a national "network on aging" consisting of the Adminis- 
tration on Aging at the Federal level, State and Area Agencies on Aging established 
under Title III of the Act, and the agencies and organizations providing direct serv- 
ices at the community level. In fiscal year 1992, Congress appropriated $846,472,000 
to support programs and activities to implement the provisions of the Act, which 
are administered by AoA. This excludes $181,000 available for the Federal Council 
on Aging under the Older Americans Act appropriation and $2,000,000 for the 
White House Conference on Aging. 

This report is divided into five sections. Section I describes key provisions to the 
1992 Amendments to the Older Americans Act. Section II provides information on 
the functions and roles of AoA offices under the recently implemented reorganiza- 
tion. Section III highlights various activities undertaken by AoA. In particular, the 



84 



National Eldercare Campaign which is a multi-year, nation-wide effort to mobilize 
resources for older persons at risk of losing their independence. The National Elder- 
care Campaign was developed in partnership with public and private agencies, other 
Federal agencies and national organizations such as the National Association of 
State Units on Aging and the National Association of Area Agencies on Aging. Sec- 
tion IV provides an overview of the provisions of Title III of the Older Americans 
Act. It summarizes the principal activities of the network of State and Area Agen- 
cies on Aging in fiscal year 1992. Section V describes the Title VI program of grants 
to Indian tribal organizations and Native Hawaiians and the efforts of the Adminis- 
tration on Aging in assessing outreach to older Native Americans. Section VI pre- 
sents a summary of AoA's fiscal year 1992 discretionary activities under Title IV 
(Research, Demonstration and Training), and a description of the fiscal year 1992 
special activities and initiatives conducted by AoA in support of the National Elder- 
care Campaign. 

SECTION I— OLDER AMERICANS ACT 1992 REAUTHORIZATION 

Congress passed the Older Americans Act Amendments of 1992 reauthorization 
bill in late September, 1992. The bill, H.R. 2967, was signed by the President into 
law on September 30. The new law, P.L. 102-375, extends the Older Americans Act 
of 1965 (OAA) and the Native American Programs Act of 1974 (NAPA) through 
Fiscal Year 1995 and authorizes a 1994 White House Conference on Aging. 

Representatives of aging organizations and constituents had mounted a major na- 
tionwide campaign to urge Congress and the White House to get the authorization 
bill passed before the 102nd Congress adjourned in early October, and signed before 
the end of the federal fiscal year which begins on October 1. But these funds were 
not available for 1992 until the specific congressional authorization in H.R. 2967 was 
signed into law. Authorization for federal appropriations for ongoing OAA programs 
expired on September 30, 1991 because of the delayed reauthorization of the Act. In 
the interim, Congress continued funding under fiscal year 1992 appropriations legis- 
lation. Fiscal year 1992 funds appropriated for an increased per-meal payment level 
from the Department of Agriculture for nutrition programs under the OAA and for 
activities connected with the White House Conference on Aging took effect with the 
signing of the Act on September 30, 1992. 

As the Nation's major program for the social services network which delivers in- 
home and community based services to the elderly, including nutrition, the OAA 
was considerably strengthened and expanded by the 102nd Congress. Many changes 
affected the largest program of the Act, title III, which authorizes supportive, nutri- 
tion and other social services. The Commissioner on Aging of the Administration on 
Aging (hereinafter, referred to as the Commissioner) which administers the OAA, 
will now be required to approve State formulas for distribution of title III funding 
within States. The new law also greatly strengthens the targeting provisions of 
these formulas to those in greatest social or economic need, particularly to low- 
income minority individuals. There has been considerable concern about the partici- 
pation of low-income and minority older persons in programs under the Older 
Americans Act. The new law requires the Commissioner to design and implement 
uniform data collection procedures for use by State Units on Aging (SUAs). P.L. 
102-375 also requires State and Area Agencies on Aging and service providers to set 
specific objectives for improving participation by low-income minority persons, such 
as providing services in accordance with the needs of target groups instead of by 
their proportion in the population. 

Another issue dealt with in the new law concerns public and private partnerships. 
In recent years, many State and Area Agencies have developed agreements with pri- 
vate, for-profit corporations and businesses, usually to provide services for employed 
family caregivers as part of a workplace eldercare program. These initiatives have 
been seen as valuable, and had also become an issue which was addressed in the 
reauthorization process. In April of 1990, the Administration on Aging issued an in- 
struction to State Agencies on Aging encouraging title III agencies to participate in 
workplace eldercare programs with corporations, but within certain guidelines. P.L. 
102-375 further clarified this guidance by requiring title III agencies to disclose the 
nature of their public/private activities and to assure that these programs are con- 
sistent with the public purpose mission of the OAA. 

Two of the most controversial issues related to title III services considered by Con- 
gress during the reauthorization were cost sharing and access to services by rural 
elderly. Currently, the OAA allows voluntary contributions from older persons 
toward the cost of title III services. Mandatory charges by other persons are prohib- 



85 



ited. The new provisions require that states identify in their plans actual and pro- 
jected costs of providing access to services for older individuals in rural areas. 

As to more specific services, nutrition, which represents 44 percent of the Act's 
total funding, received considerable attention in the new law. Some of these new 
provisions include: 

Restricting the percentage of funds that may be transferred between title IIIB 
supportive services and IIIC nutrition services, and also between congregate and 
home-delivered meals programs (C-I and C-II). 

Increasing to 61 cents the per meal reimbursement by the U.S. Department of 
Agriculture (USDA) and adding an inflation adjustment. The reimbursement 
level is an increase of over 5 cents above the previous amount which had been 
fixed at 56.76 cents per meal since 1986. 

Authorizing a new multigenerational school-based nutrition and volunteer 
program (Part C-III). 

Requiring the Commissioner to conduct a national evaluation of the nutrition 
program, establish an advisory council and issue guidelines for specific nutri- 
tion standards. 

Requiring that meals provided by nutrition projects comply with the Dietary 
guidelines for Americans. 

Health promotion and disease prevention services under Part F of Title III 
were substantially expanded in P.L. 102-375 in an effort to help older persons 
become healthier, better nourished and more physically fit and to prevent some 
illnesses and injuries, thus reducing the need for more costly medical services. 
The reauthorization amendments intend that a regular program of services and 
information should be available to older persons in every local area through 
multipurpose senior centers, congregate meal sites, home delivered meals pro- 
grams and other appropriate sites. Although Medicare has been expanded in 
recent years to add coverage for some preventive health services, such as mam- 
mography screening, pap smears and pneumonia vaccine, little has been done to 
promote the use of these services by older persons. Many other important pre- 
ventive and health promotion services that are not covered by Medicare, such 
as smoking cessation, nutrition counseling, weight reduction, alcohol control, 
and medication management and screening can be made accessible to older per- 
sons through meals programs, senior centers and other sites. 

Supportive services for family caregivers of frail older individuals were added 
to the OAA under a new Part G of title III. Approximately 80 percent of the 
care for frail older persons is provided by families, usually women who are 
often employed. Title III-G authorizes funds to assist states in developing com- 
prehensive programs of supportive activities for caregivers such as training and 
counseling, assistance in forming or participating in support groups, informa- 
tion on obtaining in-home and respite services and other nonfinancial support. 

A number of new research and demonstration programs were authorized for 
title IV's Training, Research, and Discretionary Program. These include pro- 
grams to provide intergenerational services, pension counseling, transportation, 
ombudsmen for older tenants of publicly assisted housing, resource centers for 
comprehensive long-term care research, and Native American Elders Resource 
Centers. 

Under another 1992 OAA amendment, national sponsors that administer title V, 
the Senior Community Service Employment Program for low-income older workers, 
will be assured a minimum funding base of about $5 million for their contract. This 
base is intended to help ensure that all contractors have a minimum level of funds 
to effectively administer the program on a national basis, which should help close 
the gap between national sponsors serving Indian, Pacific Island and Asian elders 
and other national sponsors. Currently, two of the ten national contractors receive 
about $1.3 million; the largest received over $100 million. 

Elder rights programs, focusing on helping older persons secure rights and serv- 
ices, were consolidated, amended and expanded under a new title VII in P.L. 102- 
375. The purpose of the new title is to expand the responsibility of State aging agen- 
cies for the development, management, coordination and outreach of statewide pro- 
grams and services. These include long-term care ombudsman services, legal assist- 
ance, outreach, public benefit and insurance counseling, and prevention of elder 
abuse, neglect and exploitation. 

A White House Conference on Aging, to be conducted no later than December 31, 
1994, was also authorized by the 1992 OAA amendments. The 1987 amendments had 
originally authorized a 1991 conference, in keeping with the previous decennial 
cycle. The President then called for a 1993 conference for which preparations began 
but funding authority expired in June of 1992 because of the long delay in the au- 



86 



thorization for the conference. For the first time, congressional appointees will work 
with presidential appointees on the 1994 conference policy committee. 

The Administration on Aging is currently developing regulations and working 
with State and Area Agencies to implement the new provisions of P.L. 102-375. It 
has been almost 3 years since Congress began hearings in February of 1990 in prep- 
aration for the 1991-92 reauthorization. And it will not be long before aging organi- 
zations, Congress and the Administration begin the cycle again leading toward the 
1996 OAA reauthorization. 

SECTION II— THE ADMINISTRATION ON AGING 

Role and Function of AoA 

The Administration on Aging (AoA) is located in the Office of the Secretary of the 
Department of Health and Human Services (DHHS). The agency is headed by the 
U.S. Commissioner on Aging, who is appointed by the President with confirmation 
by the Senate. The Commissioner on Aging reports directly to the Secretary. Joyce 
T. Berry, Ph.D., was appointed Acting Commissioner on Aging in April 1989. She 
was subsequently nominated by President Bush and unanimously approved by the 
Senate. She was sworn in as U.S. Commissioner on Aging in March of 1990. 

AoA programs are administered through a Central Office located in Washington, 
D.C. and 10 Regional Offices. Title II of the Older Americans Act, as amended, de- 
scribes the basic roles and functions of AoA. Chief among these are to serve as an 
effective and visible advocate for older persons (including American Indians, Alas- 
kan Natives and Native Hawaiians) within the Department and with other agencies 
and organizations at the national level and to administer the programs authorized 
by Congress under Titles III, IV, and VI of the Act. 

The U.S. Commissioner on Aging provides policy advice to the Secretary of Health 
and Human Services in matters affecting older Americans and information to other 
Federal agencies and to Congress on the characteristics, circumstances and needs of 
older persons. The Administration on Aging reviews and comments on departmental 
policies and regulations concerning services which affect the health and general 
well-being of older persons. 

In fiscal year 1992 the Administration on Aging initiated a significant reorganiza- 
tion designed to facilitate the planning and delivery of services to the nation's elder- 
ly. The major components of the reorganization are described below: 

SIGNIFICANT COMPONENTS UNITS AND PROGRAMS 

Office of State and Community Programs 

Serves as the focal point within AoA for the operation and assessment of the pro- 
grams authorized under Titles II and III of the Older Americans Act. Title II gives 
AoA the primary responsibility for advocacy in behalf of older Americans within 
the Federal government. The principal initiative under Title II at the present time 
is the Eldercare Campaign, which draws public and private organizations not tradi- 
tionally associated with the aged into elder services, particularly to those most at 
risk. Title III authorizes a formula grant program to the States for the planning and 
organization of social and support services, and for a nationwide nutrition program 
for older Americans. This program distributes approximately $750 million to the 
States, based on the number of older people in each State, which is then distributed 
within each State to Area Agencies, based on population and other factors affecting 
service delivery. 

Office of American Indian, Alaskan Native and Native Hawaiian Programs 

Serves as the focal point within AoA for the operation and assessment of the pro- 
grams authorized under Title VI of the Older Americans Act. Title VI gives AoA 
the responsibility for advocacy in behalf of Native Americans within the Federal 
Government, and authorizes grants to American Indian tribes and organizations 
serving Native Hawaiians and Alaska Natives, providing social and support serv- 
ices. The purpose of Title VI is to provide services to older Native Americans which 
is equivalent in quality to services provided under Title III through the State Agen- 
cies. The problems of older Native Americans are particularly acute, due to high 
unemployment, lack of adequate transportation, poor housing, and serious health 
problems on Indian reservations and in Native Alaskan villages. 



87 



Office of Program Development 

Conducts activities for the development of adequate knowledge for improving the 
circumstances of older people. Administers Title IV of the Older Americans Act, 
which provides for grants programs to carry out research, demonstration, and train- 
ing programs in behalf of older people. Responsible for disseminating knowledge 
gained through these activities to professional audiences and older people. In addi- 
tion to direct funding of research and training activities, this Office emphasizes co- 
operative activities with other Federal agencies, academic institutions and other 
public and private institutions associated with the aging. The aim is not only to con- 
stantly expand the body of knowledge about the needs of the aged and methods of 
meeting those needs, but to disseminate that knowledge in the most effective ways 
to the audiences where it will be effective. 

Office of Administration and Management 

Provides for administrative support and management systems within AoA. These 
cover the areas of budget and finance, grants management, personnel, procurement, 
material and facilities management, management systems, information resources 
management, and similar support services. This Office has been most strongly im- 
pacted by the change in AoA's status to the Operating Division level. Until the be- 
ginning of Fiscal 1992, AoA received support services through its parent organiza- 
tion. During the past year, this Office has absorbed most of the support activities 
which had previously been provided external to AoA. 

Office of Ex terna I Affa irs 

This new unit in AoA coordinates all liaison activities with outside groups, other 
than grantees, contractors and professional organizations. This office manages the 
public education and information, and the legislative development and liaison func- 
tions. Legislative activities have been expanded. Other responsibilities include the 
publication of Aging magazine, the celebration of Older Americans' Month, and 
other events, publications and public inquiries. 

Office of Policy Coordination and Analysis 

Analyzes and interprets issues related to AoA program policy; develops and inter- 
prets AoA goals, priorities and strategies; performs statistical analyses related to 
the aging; manages a program for the collection and analysis of demographic and 
socio-economic information related to the aging; and coordinates the review and de- 
velopment of policy in AoA. Although this Office is new in this Fiscal Year, the ac- 
tivities are not new to AoA. There has been a significant increase in emphasis on 
long term policy and strategy, since the number and percentage of older people will 
significantly increase over the next 30 years. Even more significantly, from the 
standpoint of cost and human need, the number and percentage of people over age 
85 will increase at a much higher ratio than that of the group from 65 to 85. 

Office of Field Operations 

Responsible for overseeing the activities of the ten Regional Offices of AoA in the 
execution of their responsibilities. Coordinates and facilitates contacts between AoA 
Central Office and Regional Offices. This Office is also new this year, and responds 
to the increased diversity of activities in Regional Offices, and the greater need for 
coordination and liaison. 

SECTION III— TITLE III SUPPORTIVE AND NUTRITION SERVICES 

Introduction 

The Administration on Aging (AoA) is the lead component within the Department 
of Health and Human Services on all issues concerning Aging. It advocates for the 
needs of the elderly in program planning and policy development; provides technical 
assistance; issues best practices guidelines; and initiates policy relative to funding 
the States and Territories for the provision of services to older Americans under 
Title III (Grants for State and Community Programs on Aging.) 

Each State Agency is required to subdivide the State into Planning and Service 
Areas (PSAs) and to designate within each PSA an Area Agency on Aging (AAA) to 
be specifically responsible for carrying out the purposes of the Act within the PSA. 
While most States have a statewide network of Area Agencies on Aging, nine States 



88 



and five Territories have designated their entire geographic area as a single PSA I 
with the State agency performing the Area Agency functions because of their small 
geographic areas or population size. Single PSA States include: Alaska, Delaware, 
Nevada, New Hampshire, North Dakota, Rhode Island, South Dakota, Wyoming, 
and the District of Columbia. 

STATE AGENCIES ON AGING 

The Older Americans Act intends that the State Agency on Aging shall be the 
leader relative to all aging issues on behalf of all older persons in the State. This i 
means that the State Agency proactively carries out a wide range of functions relat- \ 
ed to advocacy, planning, coordination, interagency linkages, information sharing, 
brokering, monitoring, and evaluation designed to develop or enhance services for I 
older persons throughout the State. Fifty-seven States and other jurisdictions re- 
ceive support under Title III of the Act. States may elect durations of 2, 3 or 4 years 
for State and Area Plans. 

The State Agencies assure that the resources made available to Area Agencies on 
Aging under the Older Americans Act are used to carry out the Area Agency mis- I 
sion of assisting older persons in leading independent, meaningful and dignified 
lives in their own homes and communities as long as possible. 

State and Area Agencies on Aging work to facilitate the most effective use of all , 
community resources, both public and private, to provide for appropriate services to 
older persons within the many communities of the Planning and Service Area. To 
effectively accomplish this goal, there must be a communitywide effort with all ap- | 
propriate resources, programs and personnel carefully coordinated. 

AREA AGENCIES ON AGING 

In fiscal year 1991, there were over 670 Area Agencies on Aging operating under 
Title III of the Act. As of the end of fiscal year 1991, there were approximately 679 
Planning and Service Areas, including the 14 Single Planning and Service Areas, 
previously mentioned, covering nine whole States and five Territories. An Area 
Agency on Aging may be a public or private organization, an Indian Tribe or a sub- 
State regional body. Area Agencies on Aging have the major responsibility for the 
administration, at the sub-State level, of Title III funds for supportive and nutrition 
services. Area Agencies receive their funds from the State Agency on Aging and 
then award grants and contracts to local supportive and nutrition service providers 
under an approved area plan. 

Area Agencies on Aging are responsible for providing technical assistance to and 
monitoring the effectiveness and efficiency of, their respective service providers. 
Through their coordination and planning activities, Area Agencies also address the 
concerns of older persons at the community level. Area Agencies interact with other 
local public and private agencies and organizations in order to coordinate their re- 
spective activities and elicit additional resources to be used on behalf of older per- 
sons. 

FUNDING STATE AND AREA AGENCIES ON AGING 

State Agencies on Aging received a total of $454.3 million of Title III funds during I 
fiscal year 1991 and $464 million in fiscal year 1992. Funds under this Title of the 
Act are made available to the States on a formula basis upon approval of State i 
Plans by AoA Regional Offices. States then allocate funds to Area Agencies based 
upon approved Area Plans to pay up to 85 percent of the costs of supportive services 
and senior centers, and nutrition services. In most cases, Area Agencies on Aging 
then arrange with both nonprofit and proprietary service providers to deliver nutri- 
tion and other services described in the Area Plan. 

In general, funds provided to Area Agencies are used for the administration and 
provision of a wide range of supportive and nutrition services authorized under 
Parts B (including Ombudsman Activities), C, D, and G of Title III as described in 
the next paragraph. 

TITLE III SERVICES 

Title III activities conducted in the States during fiscal year 1991* were based 
upon State plans ranging in duration from 2 to 4 years. In fiscal year 1991 six sepa- 



*Note: Fiscal year 1992 service data will be reported by State Agencies on Aging to the Ad- 
ministration on Aging in January, 1993, following the close of the previous fiscal year (which 
ended on September 30, 1992). 



I rate allocations under Title III were made to States for: (a) supportive services and 
senior center operations; (b) congregate nutrition services; (c) home-delivered meals; 

| (d) in-home services for the frail elderly; (e) programs to prevent abuse, neglect, and 

i exploitation of older individuals; and (f) ombudsman activities. 

Title III-B supportive services are designed to provide assistance to all older per- 
sons, with particular attention to older persons in greatest economic or social need. 
Most supportive services fall under three broad categories: access services; in-home 
services; and other community and neighborhood services. Access services are trans- 
portation, outreach, and information and referral. Most in-home services are home- 
maker, personal care, chore, and/or visiting and telephone reassurance. Community 
and neighborhood services include legal services, residential repair, escort services, 
health services, physical fitness programs, pre-retirement and second career counsel- 
ing, and other services. 

Data on Title III services and program operations are reflected in State Program 
Reports which are sent to AoA Central Office each year by the State Agencies on 
Aging through AoA's 10 Regional Offices. The Title III State Program Reports for 
fiscal year 1990 were analyzed during fiscal year 1991. These data provide a nation- 
al summary of the Title III program including such information as participation 
levels, expenditures, and units of service by service category. This information is re- 
sponsive to Sections 207 (a)(1), (a)(2) and (a)(4), as required by the Older Americans 
Act as amended. Selected program data are presented in the following paragraphs. 

Title III-B Supportive Services 

In fiscal year 1991, the Title III-B program reached an estimated 6.9 million older 
clients in need of access, in-home, and community-based services. In fiscal year 1991, 
17 percent of all participants were racial and ethnic minorities and 36 percent were 
low income. In the area of access services, transportation was the most frequently 
provided service, followed by information and referral. In the area of in-home serv- 
ices, personal care was reported most frequently, followed by housekeeping assist- 
ance. In the community-based services area, recreational services were most fre- 
quently provided, followed by education and training, escort, and legal services. 

Title III-C, Congregate and Home Delivered Nutrition Services 

Congregate and Home-Delivered Nutrition Services, authorized by Title III-C, con- 
tinue to be an integral part of the systems which communities are developing to 
assist their older citizens in maintaining independence and remaining in their own 
homes as long as possible. 

Congregate Nutrition Services 

Over 136.6 million congregate meals were served to older people and their spouses 
during fiscal year 1991. In addition to Title III-C funds, these meals are also supple- 
mented and supported by U.S. Department of Agriculture funds; Social Services 
Block Grant program funds; other Federal, State, and local funds; and participant 
contributions. Over 2.5 million elderly received meals at congregate sites. 

Home-Delivered Meals 

Home-delivered meals are also critical to the maintenance of independence for 
older persons who are unable to participate in congregate meals programs. During 
fiscal year 1991, 101.6 million meals were provided to the homebound elderly from 
Title III-C and other funding sources. This number represents an increase over the 
99.6 million home-delivered meals served in fiscal year 1989. A total of 845,976 older 
persons received home-delivered meals. 

Title III-D, In-Home Services for Frail Elderly 

During fiscal year 1991, more than 77,875 frail older persons received in-home 
services under the Title III-D program. 

Title III-G, Prevention of Abuse, Neglect, and Exploitation of Older Individuals 

Established by the 1987 Amendments to the Older Americans Act, Title III-G was 
first funded in fiscal year 1991. Program data indicates that more than $830,000 was 
expended for Title III-G services representing 2.5 percent of total Title III funding 
for supportive services. 



90 



OMBUDSMAN PROGRAMS 

State Agencies use part of their Title III-B (Supportive Services and Senior Cen- 
ters) funds and funds from other sources to establish and maintain long-term care 
ombudsman programs at the State and sub-State levels. In addition, in fiscal year 
1991 Congress provided a separate allocation of funds for ombudsman activities. Pro- 
gram data related to this funding shows that States expended an aggregate amount 
of $2,015,049 for Ombudsman programs representing 5.9 percent of total Title III 
funding for supportive services. 

Through their ombudsman programs, States have addressed such issues as nurs- 
ing home regulations, abuse of residents' personal funds, and restrictions on access 
to nursing homes. Complaint statistics and program data for the fiscal year 1990 
reporting period were analyzed during fiscal year 1991. Some highlights of these 
data are as follows: 

During fiscal year 1991 there were 551 sub-state programs. 
Total funding for State and local ombudsman programs in fiscal year 1991 in- 
creased from approximately $27.9 million in fiscal year 1990 to $34 million in 
fiscal year 1991. In addition to Title III-B funds, State and local governments 
used funds from other sources, including State, county, and local revenues, 
grants under Titles IV and V of the Older Americans Act, and other funding 
sources. 

WAIVERS AS RELATED TO PRIORITY SERVICES 

The Older Americans Act, as amended, requires that the Administration on Aging 
collect and report special information about access, in-home, and legal assistance 
services. Section 307(a)(22) requires that each State Agency include in its State Plan 
a minimum percentage of Title III-B funds which each Area Agency must expend 
on these services. Otherwise, the State grants a waiver to the Area Agency. Section 
306(a)(2) describes the requirements which must be met by an Area Agency when 
requesting a waiver from providing the required minimum amount for one or more 
of these priority services (access, in-home, and legal assistance) and by the State 
Agency in granting any such waiver request. 

Pursuant to Sections 207(a)(2) and 306(b)(2)(d) of the Act, the Administration on 
Aging compiles a report on waivers of priority services as required under the Act; 
however the data for this year's report are not available at the time of submission 
of this report. 

The Act permits State Agencies to grant waivers to Area Agencies that have not 
expended the mandated minimums for priority services. The Act also requires the 
State Agency to follow rigorous procedures in their respective granting and review 
of waivers. 

The data from the previous year suggest that there is a high level of compliance 
with the provisions of the Act. The States have set minimum expenditure levels for 
the priority services. For most Area Agencies on Aging the States report that the 
actual expenditure levels have been met. 

It is clear that the States have taken the Congressional mandate seriously as well 
as the freedom to define appropriate proportion. 

ADVOCACY AND PARTNERSHIPS 

In advocating for older persons, State and Area Agencies on Aging review and 
comment on State and community policies, programs, and issues; provide testimony 
at public hearings; publish reports; coordinate and provide technical assistance to 
other public and private agencies and organizations; and leverage resources from 
other Federal, State, and local programs, as well as private charitable and business 
resources. 

NONFEDERAL RESOURCES AND PROGRAM INCOME 

The Title III program has evolved from a relatively simple program of community 
service projects for older persons into a complex and highly differentiated "national 
network on aging" currently consisting of 57 State Agencies and over 670 Area 
Agencies on Aging and more than 25,000 local nutrition and supportive service pro- 
viders. These nutrition and supportive service providers are local public, private, or 
voluntary organizations. Not only do the State and Area Agencies on Aging use 
Title III moneys to provide for services, they also are instrumental in leveraging 
other public and private moneys in addressing the needs of older persons. 

Title III regulations (45 C.F.R. Part 1321) require each service provider to "pro- 
vide each older person [receiving services] with a full and free opportunity to con- 



91 



I tribute toward the cost of the service." Although AoA emphasizes through the aging 
network that this is not a fee and that contributions are entirely voluntary, these 
contributions have been steadily increasing ranging from $79 million in fiscal year 
1979 to approximately $182 million in fiscal year 1991. 

Business and Aging 

i 

The Administration on Aging (AoA) is reaching out to members of the business 
community to encourage their commitment to aging concerns both as employers and 
community citizens. In addition to the following initiatives, the Commissioner on 
Aging and staff of the Administration on Aging have made numerous presentations 
to business representatives on an individual basis and in public forums sponsored by 
national associations and industries. 

Business and Aging Leadership Awards 

AoA has established a Business and Aging Leadership Awards Program to reward 
j companies that have made a commitment to aging issues and to highlight their ex- 
emplary programs. Over 165 companies were nominated for initiatives they had un- 
dertaken in four categories: Employment and Training, Work/ Family Issues, Health 
Promotion, and Volunteerism /Community Initiatives. In a May 1991 ceremony, 
Commissioner Berry and Secretary Sullivan presented awards to 23 companies in 
recognition of their accomplishments. 

Private Sector Management Committee 

In 1990, AoA sought to increase the involvement of a newly established Private 
Sector Management Committee, comprised of approximately 20 key management of- 
ficials from selected business organizations and industries. The Committee advises 
AoA on issues that confront the business community as it deals with an aging 
America. 

American Express 

AoA and American Express have undertaken a joint initiative to develop a model 
public/private sector corporate eldercare program. Through this 2-year initiative, 
the Area Agencies on Aging in Fort Lauderdale and Jacksonville, Florida are work- 
ing with their local American Express offices to develop an eldercare program for 
American Express employees. It is anticipated that the program will be replicated 
in other communities across the Nation. 

Foundation Roundtable 

AoA has begun to work with the foundation community, including a number of 
corporate foundations. In April 1991, the Commissioner convened a roundtable of 
executives from approximately 35 foundations. The roundtable provided for an ex- 
change of ideas and an opportunity to encourage foundation involvement in aging 
issues and the National Eldercare Campaign. 

Transportation 

AoA has continued to award the National Eldercare Institute on Transportation 
cooperative agreement to the Community Transportation Association of America. 
The National Eldercare Institute on Transportation will be discussed under Section 
V of this Report. 

Under an agreement with the Department of Transportation's Federal Transit 
Administration (FTA), the Administration on Aging and FTA are continuing joint 
support of the Chickasaw Nation's volunteer van transportation program which 
serves elderly and low-income Native Americans living in the Oklahoma service 
area of the Chickasaw Nation. As a result of this grant, rural Native Americans are 
now able to participate in programs that provide nutrition, health, recreation and 
other supportive services. Home-delivered meals are the most frequently used serv- 
ice. Other services include senior center meals and activities, shopping for necessi- 
ties, social services, and medical assistance and appointments. 

AoA is a member of the Joint DOT/DHHS Coordinating Council on Human Serv- 
ice Transportation. As a member, AoA works with the Council to address Federal 
barriers that impact on the coordination of transportation services, to promote co- 
ordinated transportation planning and programming, and to coordinate technical as- 
sistance, program guidance, and information dissemination. In that light, AoA par- 



65-505 - 93 - 4 



92 

ticipated in a Coordination Roundtable sponsored by the Council. At the Roundta- 1 
ble, participants discussed issues surrounding the development and provision of co- 
ordinated transportation services and recommended actions to encourage and facili- I 
tate coordinated transportation. 

AoA has also prepared and disseminated an information memorandum to the j 
State and Area Agencies on Aging regarding the Americans With Disabilities Act ' 
(ADA), which has broadened the perspective on providing human service transporta- , 
tion. The impact of this landmark legislation, especially as it relates to the elderly, 
is not yet fully known. 

AoA is working closely with the Department's technical assistance efforts on a | 
"Study to Analyze Factors Affecting Transportation Needs of the Elderly in Five , 
Counties of Maryland." Ecosometrics, Inc. will prepare a written report for DHHS I 
and AoA based on an analyses of relationship patterns between transportation and ( 
aging issues. This is a new short-term project under the Department. 

AoA participated in the 13th National Conference on Accessible Transportation 
and Mobility in Tampa, Florida. AoA presented information at the Conference on 
Federal Program Initiatives as they relate to transportation and aging issues. 

Employment 

Regional Offices in cooperation with the Department of Labor have sponsored em- 
ployment and training conferences which target Older Worker employment opportu- ' 
nities, placement, and retention. 

AoA has funded various types of research and demonstration projects which have 
developed training materials and techniques to improve and enhance employment I 
opportunities for Older Workers. 

Through the funding of dissemination projects, AoA has targeted employers and 
potential employers to receive information on the abilities of older workers and 
dispel myths related to aging which projects a negative image of the older worker. 

AoA has funded an National Eldercare Institute on Employment and Volunteer- 
ism which will be located at the University of Maryland, Center on Aging. 

Collaboration With Social Security and Health Care Financing 
Administrations 

In fiscal year 1990, the Administration on Aging, the Social Security Administra- i 
tion (SSA), and the Health Care Financing Administration (HCFA) signed a Memo- 
randum of Understanding to promote and enhance collaboration of aging services. 
Since then, AoA, SSA, and HCFA have worked jointly to develop initiatives that 
support the following objectives of the Understanding: 

(1) To improve the coordination of services funded under the program authori- 
ties of AoA, SSA, and HCFA which relate to older persons; 

(2) To increase public awareness of SSA and HCFA entitlement programs, 
AoA's nutrition and supportive services programs, and other programs that pro- ' 
mote the well-being of older persons; 

(3) To increase older persons participation in SSA and HCFA entitlement pro- 
grams, AoA's nutrition and supportive services programs, and other programs 
which promote the well-being of older persons through special outreach efforts 
that focus on "hard to reach" individuals such as low-income older persons who 
are members of minority groups, elderly persons who do not speak English, and 
older persons living in rural areas; 

(4) To reduce the elderly's dependence on entitlement programs by improving 
their personal financial security and increasing employment opportunities for 
older persons, particularly those with disabilities; and 

(5) To improve health care for vulnerable older people. 

During fiscal year 1992 the following activities were undertaken in support of this 
MOU: 

SSI Outreach Efforts 

AoA and SSA issued discretionary grant announcements which sought project 
proposals that would demonstrate innovative, transferrable approaches for increas- 
ing both public awareness and participation in the Supplemental Security Income 
and other public benefit programs. The work group sought the collaboration of SSA 
and AoA in developing the announcement, disseminating the announcement to the 
aging agencies and organizations, and reviewing the grant applications. AoA encour- 
aged the State and Area Agencies on Aging, and Tribal Organizations to submit ap- 



93 



!| plications for fiscal year 1992 funds for a series of the Social Security Administra- 
I tion SSI Outreach Demonstrations. 

AoA/SSA/HCFA Information Dissemination 

i AoA and SSA assisted HCFA in disseminating a variety of materials, including 
videotapes, to their respective networks, ranging from information on the Qualified 
Medicare Beneficiary program and Medigap Insurance Counseling program to other 
information about programs and requirements under the Social Security Act. AoA 
also assisted SSA in distributing SSI Outreach information and posters to the State 
and Area Agencies on Aging, Tribal Organizations and the Leadership Council on 
Aging Organizations. In addition, AoA encouraged State and Area Agencies to 
submit applications for the HCFA Health Insurance Counseling and State Assist- 
ance program. 

SECTION IV— SERVICES TO OLDER NATIVE AMERICANS 
Services to Older Native Americans 
title vi grants for native americans 

Under Title VI of the Older Americans Act, the Administration on Aging annual- 
ly awards grants to provide supportive and nutritional services for older Native 
Americans. The Older Americans Act in 1978, added Title VI — "Grants to Indian 
Tribes." In the Older Americans Act Amendments of 1987 (P.L. 100-175) Title VI 
was renamed "Grants for Native Americans," and older Native Hawaiians were 
added to the American Indians and Alaskan Natives already being served by Title 
VI. Title VI was divided into two parts, Part A — Indian Program, and Part B — 
Native Hawaiian Program. The first grant under Part B was made in Fiscal Year 
1989. The 1992 Amendments to the Older Americans Act provided a directive for 
coordination between Title VI and Title III and a "hold harmless" clause for all cur- 
rent Title VI grantees (subject to the availability of appropriations). Of the amount 
appropriated for Title VI for each fiscal year, 90 percent was provided to carry out 
Part A and 10 percent was provided to carry out Part B. 

In Fiscal Year 1992, under Title VI Part A, eight new grants were awarded, four 
from the breakup of two previously funded consortia and four new Tribal organiza- 
tions. There are now 216 Title VI Part A grantees. The funding increased from 
$13,133,811 for Fiscal Year 1991 to $13,581,00 for Fiscal Year 1992. 

One grant was awarded under Title VI Part B. The funds awarded, as specified by 
the 1987 Amendments, remained the same for Fiscal Year 1992 at $1,505,000. 

ELDERS ELIGIBLE UNDER TITLE VI 

Persons eligible for services under Title VI Part A are tribal members age 60 or 
over living in a Tribe's Title VI service area, and members under age 60 if the Tribe 
has selected a younger age for "older Indian." The Older Americans Act Amend- 
ments of 1981 allowed Tribes to set a younger age for "older Indian", if considered 
appropriate. The 216 grantees of Title VI Part A for Fiscal Year 1992 estimated that 
97,609 older Indians were eligible for services, including 77,850 age 60 or over, and 
19,759 under age 60. 

For services under Title VI Part B, the Native Hawaiians must be age 60 or over. 
Alu Like, the statewide grantee, estimated that 1,300 older Native Hawaiians were 
in the proposed Title VI Part B service areas on the five major islands and thus 
were eligible for Title VI services. The grantee estimated that there were a total of 
13,000 older Native Hawaiians in the entire State of Hawaii. 

SERVICES UNDER TITLE VI 

Congregate and home-delivered meals, and a variety of supportive services were 
provided by Indian Tribes Under Title VI Part A. All grantees provided the re- 
quired service of information and referral unless other arrangements existed. Other 
supportive services that were provided included transportation, counseling and 
home assistance services. 

The most recent service delivery data available is for Fiscal Year 1991. Approxi- 
mately 2,293,837 meals were provided under Title VI Part A in fiscal Year 1991, 
including 1,099,705 congregate meals, and 1,194,132 home-delivered meals. 

Approximately 32,000 meals were provided under Title VI Part B in Fiscal year 
1991. 



94 



CONTRIBUTIONS TO THE ELDERCARE CAMPAIGN 

In 1991 the Office of American Indian, Alaskan Native, Native Hawaiian Pro- 
gram established an Eldercare Work Group with representatives from the Adminis- 
tration on Aging central office, three regional offices, and eight Tribal Organiza- 
tions. The purpose of the workgroup was to provide a means of exchange between 
the participating members in order to develop and promote the implementation of 
an effective strategy for eldercare in diverse Indian communities. Workgroup ac- 
complishments included: submission of articles and updates by workgroup members 
for "In Touch" and "Aging Magazine;" development of a draft fact sheet for Elder- 
care in Indian communities; and appointment of tribal representatives to the adviso- 
ry boards of the National Eldercare Institute on Nutrition, the National Eldercare 
Institute on Transportation, and the National Eldercare Institute on Human Re- 
sources. 

The Eldercare campaign is being further promoted by the National Title VI Direc- 
tors Association. This Association was awarded a grant by the Administration on 
Aging in 1991 to conduct a public awareness campaign on the needs of "at-risk" 
Native American, Native Alaskan and Native Hawaiian elders. The purpose of the 
grant is to educate individuals, agencies, organizations, and businesses on the needs 
of "at risk" Native American, Native Alaskan and Native Hawaiian elders and to 
secure resources to improve the quality and increase services to this population. In 
1992 a video and information packet illustrating the needs of this population has 
since been developed. Film presentations have been delivered on national, regional, 
and local levels in such diverse geographic locations as New York, Washington, DC, 
Arizona, Oklahoma, Washington, Kansas, New Mexico, and Wisconsin. 

ADMINISTRATIVE PROCEDURES 

A proposed monitoring policy for Title VI grants was developed. The "Title VI 
Compliance Monitoring Instructions and Guide" was field tested in one region. Fur- 
ther field tests are necessary before finalizing the monitoring guide and implement- 
ing the monitoring plan. The monitoring plan must be implemented in fiscal year 
1993. 

TECHNICAL ASSISTANCE 

In Fiscal Year 1992 a decentralized method of providing training and technical 
assistance to Title VI grantees was implemented in an effort to provide more flexi- 
bility in responding to an increasingly diversified set of individual grantee needs. 
Under this decentralized approach, the country was divided into three sections. A 
lead Region in each section was designated to manage the planning and acquisition 
of training and technical assistance. Training and technical assistance is being de- 
livered in a wide variety of areas including Title Ill/Title VI coordination, budget 
and program management, nutrition, and service development. 

TITLE HI/TITLE VI COORDINATION 

In 1992, grantees were asked to include information on Title Ill/Title VI coordina- 
tion in their area in the grant applications. At the same time, a working relation- 
ship has been developed with NASUA to evaluate the adequacy of outreach under 
Title III and Title VI so recommendations can be made to the Commissioner on nec- 
essary action to improve service delivery, outreach, coordination and particular 
problems faced by older Native Americans. 

OFFICE FOR AMERICAN INDIAN, ALASKAN NATIVE, AND NATIVE HAWAIIAN PROGRAMS 

In 1992 the Associate Commissioner for Office for American Indian, Alaskan 
Native, and Native Hawaiian Programs has continued to serve as the focal point 
within AoA for the operation and assessment of programs authorized under Title VI 
of the Older Americans Act (OAA) and to provide program and policy direction to 
the 10 Regional Offices of AoA in the execution of their Title VI responsibilities. 
The Associate Commissioner has also continued to serve as the effective and visible 
advocate on behalf of older Native Americans, to coordinate activities with other 
Federal departments and agencies, to administer and evaluate grants provided 
under the OAA to Indian Tribes and public and nonprofit private organizations 
servicing Native Hawaiians, to collect and disseminate information related to the 
problems of older Native Americans and to promote coordination between the ad- 
ministration of Title III and the administration of Title VI. 



95 



INTERAGENCY TASK FORCE ON OLDER INDIANS 

The 1987 Amendments in Section 134(d) directed the Commissioner on Aging to 
establish a permanent Interagency Task Force on Older Indians, with representa- 
tives of departments and agencies of the Federal Government with an interest in 
older Indians. This Task Force was established in Fiscal Year 1990 and became fully 
functioning in Fiscal Year 1991. 

In Fiscal Year 1992 the Interagency Task Force on Older Indians established 
three major priority areas: Health/Long Term Care; Transportation; and Data De- 
velopment and Dissemination. These areas were chosen on the basis of post testimo- 
ny from experts from different Indian communities and from the preliminary report 
which the National Indian Council on Aging prepared as a basis for a National 
Policy for Older Indians. Participants on the Task Force will develop reports on the 
issues in these priority areas, recommendations for improved collaboration between 
and within Federal agencies and recommendations for Congressional review of key 
statutorily based issues. The subcommittee reports will be reviewed and discussed 
by the full Task Force. It is planned that a final report will be issued to all partici- 
pating Federal agencies by the end of the calendar year, 1993. 

The Task Force also worked with the White House Conference on Aging to inform 
them of issues of concern by the elderly in Indian communities in Federal and State 
recognized tribes as well as Urban based organizations. 

SECTION V — AoA DISCRETIONARY PROGRAMS 

A. Purpose of Title IV 

Title IV — Training, Research, and Discretionary Projects and Programs — supports 
the goals of the Older Americans Act by funding model projects and research and 
by educating and training professionals in fields which have an impact on the aging. 
Through these projects, the Administration on Aging (AoA) provides valuable sup- 
port to the National Eldercare Campaign, helps to build the capacity of State and 
Area Agencies on Aging and other organizations to provide services to the aging, 
promotes linkages among organizations which serve older persons, and takes a lead- 
ership role in better preparing the country for an aging society. Title IV funds are 
also used to support short-term evaluations, studies, and other special activities pe- 
riodically specified by Congress under reauthorizations of the act. 

Projects funded under Title IV complement and support the services provided 
through other sections of the Older Americans Act. Training and technical assist- 
ance to State and Area Agencies on Aging is provided through National Eldercare 
Institutes with expertise in such areas as community based long-term care, elder 
abuse and ombudsman programs, transportation, nutrition, and housing. Through 
Title IV, AoA promotes minority management and leadership of aging programs 
and agencies, the growth of college/ university faculty who are knowledgeable about 
the aging process and informed on aging issues, and career preparation of students 
in disciplines relating to aging. Health promotion activities for older Americans are 
supported through Title IV by a number of projects as are model projects for serv- 
ing the vulnerable elderly. Strategies for cultivating public/ private partnerships 
and strengthening the family are developed through Title IV as well as models for 
using older persons as resources. As part of the Small Business Innovation Research 
Program, AoA also awards contracts to small businesses to develop innovative tech- 
nology which will benefit the elderly. 

In fiscal year 1992, a major portion of Title IV funding supported activities of the 
National Eldercare Campaign and its goals to create public awareness, broaden the 
involvement of individuals and organizations, and promote community action on 
behalf of older persons at risk. The first part of this section describes the project 
grants and contracts which support organizations assisting the Administration on 
Aging in the conduct of this campaign, including promotion, training, and technical 
assistance. The second part of this section describes a wide variety of activities sup- 
ported by Title IV funds which carry out both specific and general mandates of the 
act. Activities are described by topical area or focus and include projects funded in 
prior fiscal years, but still active in fiscal year 1992. 

B. Activities in Support of the National Eldercare Campaign 

During fiscal year 1992, Title IV funds were used to continue support of the Na- 
tional Eldercare Campaign and its goals to increase advocacy, collective planning, 
and action on behalf of the most vulnerable older Americans. Six components of the 
National Eldercare Campaign, initiated in fiscal year 1991, were ongoing on fiscal 



96 



year 1992 — (1) grants to national organizations for promotion of National Eldercare 
Campaign goals through activities of their networks; (2) Project CARE grants to 
State and Area Agencies on Aging to encourage development of coalitions of local 
organizations and businesses; (3) grants to National Eldercare Institutes to advance 
our knowledge base in several important issue areas and to provide technical assist- 
ance and training; (4) grants to State Agencies on Aging to foster development of an 
Older Americans Act Eldercare Volunteer Corps; (5) a contract to develop national 
media materials; and (6) a contract to support training and technical assistance in 
coalition-building. Additional project grants were awarded in fiscal year 1992 under 
the first four components: national organizations, the Eldercare Volunteer Corps, 
Project CARE coalitions, and the National Eldercare Institutes. 

1. NATIONAL ORGANIZATIONS 

In fiscal year 1992, as in fiscal year 1991, the Administration on Aging solicited 
project applications from national organizations to initiate and carry-out initiatives 
within their organization and among their members in support of the National El- 
dercare Campaign, with specific attention to the goals of Project CARE — Communi- 
ty Action to Reach the Elderly. The competition for 1992 support, as in fiscal year 
1991 was held through the annual Discretionary Funds Program Announcement in 
two categories, one for national associations and organizations whose predominant 
focus is not aging, and another for national aging organizations. 

a. Building Public Awareness About Eldercare in Non-Aging Organizations 

Twelve national organizations were awarded grants in fiscal year 1992 to work 
through local affiliate chapters to promote grass-roots efforts that would respond to 
problems of the at-risk elderly. The activities of these new awards are similar in 
purpose to the 10 projects awarded in fiscal year 1991 whose public information and 
dissemination activities served as a model for new applicants. 

FY 1992 NEW STARTS 

The Helen Keller National Center for Deaf-Blind Youth and Adults will increase 
the awareness of professionals in aging and other older adults about the effects of 
sensory loss and the rehabilitative approaches necessary to assist older persons with 
sensory impairments. Three Helen Keller Center affiliates will implement a commu- 
nity based Confident Living Program that provides to older persons with sensory 
loss (1) training in coping skills and (2) techniques for adapting activities of daily 
living. 

The American Foundation for the Blind will develop a five-site collective action 
and advocacy model to address the eldercare issue of improving access to communi- 
ty services and resources for older visually impaired persons. Local affiliates will 
work with eldercare coalitions and disseminate information about local eldercare 
campaigns to their members. 

The Arc — a national organization for families of children with mental retarda- 
tion — will provide training and technical assistance for six selected affiliate chap- 
ters to demonstrate programs that assist elderly parents of an aging son or daugh- 
ter with mental retardation. Each demonstration will help families to develop plans 
for the care of their son or daughter which takes into account the future possibility 
that the parents will not be able to carry out their key care-giving roles. 

The National Urban League will provide in-home, transportation, and nutrition 
services and health care information to the at-risk elderly in their home or local 
communities. 

The National Council of La Raza project, Ancianos Capaces de Triunfar (ACT), 
will empower Hispanic elderly to become aging advocates, increase the capacity of 
Hispanic community-based organizations to mobilize collective action and advocacy 
efforts on behalf of the Hispanic elderly, and increase their access to eldercare serv- 
ices. 

The National Council of Jewish Women will train volunteers to organize local 
coalitions and community education campaigns directed at family caregivers and 
employers in nine geographically and demographically diverse communities. 

The National Baptist Convention will establish National Baptist Convention in- 
home care programs in four States (New York, New Jersey, Missouri, Virginia) and 
the District of Columbia. 

The Boys and Girls Clubs of America will develop and disseminate to local affili- 
ates a program that enables youth to plan and carry out community eldercare advo- 
cacy and service activities for the at-risk elderly. 



97 



The George Meany Center for Labor Studies will create organizational structures 
which will form local coalitions and support union retirees in the provision of social 
services to the at-risk elderly in their communities. 

The Points of Light Foundation will demonstrate how local volunteer centers can 
play a key leadership role in mobilizing new nontraditional volunteer resources to 
respond to the needs of at-risk elderly. 

The National Recreation and Parks Association will work with public park and 
recreation agencies so that they can effectively cooperate with the traditional aging 
network in serving the at-risk elderly through the existing service system. 

The National Association for Equal Opportunity in Higher Education (NAFEO) 
will work to stimulate linkages among Historically Black Colleges and Universities 
(HBCUs) and their respective communities to develop strategies for improving the 
lives of minority older persons. Project activities include training, technical assist- 
ance and information dissemination. These will be carried out through a series of 
workshops and other targeted efforts. Anticipated products include models of 
HBCU-community cooperation to be developed and demonstrated by three HBCUs — 
Langston University in Oklahoma and Morgan State University and Sojourner- 
Douglas College in Baltimore, Maryland. 

PROJECTS FUNDED IN FY 1991 

The Public Health Foundation (Washington, DC) has developed a guide, "Wearing 
Well: A Guide to Public Health Practice for Eldercare," for practitioners to use in 
determining the needs of the older population and planning appropriate services. 
The guide uses a multidisciplinary approach to enhance the focus on aging in the 
areas of public health nursing, nutrition, social work, dentistry, and health promo- 
tion. A Commissioner's Award for Public Health Excellence in Eldercare was estab- 
lished to recognize excellence in local public health programs. 

The Health Insurance Association of America (Washington, DC) prepared a self- 
study education course on long term care protection for insurers and their agents, 
employee benefit specialists, employers, financial planners and providers. The cur- 
riculum, which includes a textbook on long-term care and long-term care insurance, 
a study guide and a course examination, will be submitted to State licensing agen- 
cies for continuing education credit approval. 

The American Medical Association (Chicago, ID is using a train-the-trainer ap- 
proach to increase physician awareness of the needs of homebound elderly and to 
maximize the capacity of physicians to provide in-home medical management. Clini- 
cal seminars conducted in Illinois, Arizona, Maryland and Texas have used materi- 
als developed during the project, including: (1) Guidelines for Medical Management 
of In-Home Care; (2) Patient Management in the Home: Lecture Notes and Case 
Studies; and (3) a monograph entitled "High Technology Home Care." 

The National Easter Seal Society (Chicago, IL) increased public awareness of the 
needs of an aging society and of older persons with disabilities through program 
demonstrations in (1) North Carolina on respite and personal care and in (2) Utah 
on mainstreaming elderly developmentally disabled people in senior centers and 
using senior volunteers to assist rural families who have children with disabilities. 

The American National Red Cross (Washington, DC) has developed a Nurses As- 
sistant's Training Program with special emphasis on training home caregivers in 
families with dependent elderly. The Red Cross is implementing it in five local chap- 
ters. 

The National Association of Social Workers (Washington, DC) conducted a series 
of activities to increase interest among its members and prepare them to work in 
the field of aging. Activities included development of sessions on aging for its World 
Assembly held July 18-22, 1992 in Washington, D.C.; the award of 10 mini-grants to 
10 local chapters to develop specific programs in the field of aging and to promote 
the National Eldercare Campaign; and the development of a document on "Social 
Work with a Culturally Diverse Population." 

Catholic Charities USA (Arlington, VA) provided information to parishes and con- 
gregations interested in learning more about linking older adults with community 
services through publication of a guidebook entitled "Linking Your Congregation 
With Services for Older Adults." The project is also expected to convene a national 
conference that focuses on access issues for at-risk, homebound older persons. 

The National Council of Negro Women (Washington, DC) is utilizing volunteer 
support networks to promote community awareness of the National Eldercare Cam- 
paign with special emphasis on minority elders in five cities (Atlanta, Los Angeles, 
New Orleans, New York, and Rulesville, MS. 

The National Black Caucus of State Legislators (Washington, DC) has held three 
eldercare forums to alert State legislators to the importance of the problems of the 



98 



at-risk elderly and provided fact sheets on important issues in aging that have im- 
plications for State legislative action. 

The American Institute of Architects/ Association of Collegiate Schools of Archi- 
tecture (Washington, DC) have continued their efforts to provide information to 
practitioners and students highlighting the need for innovative designs for older 
persons housing. The Design for Aging Network has been established and a mem- 
bership directory has been distributed to members. A guidelines report entitled 
"Better Environmental Design for Older People: Strategies for Collaboration in an 
Era of Universal Design" will be distributed in the near future. 

The National Association of Counties (Washington, DC) continues their efforts to 
develop and enhance the capacity of county governments to respond to the chal- 
lenges resulting from the growth in our aging population. A series of workshops 
have been delivered at NACO's national conference, a national Videoconference 
with downlinks to a majority of the States has been conducted, and an Aging 
Awareness Kit has been distributed to county governments. 

b. Eldercare Advocacy by National Aging Organizations 

Six new awards were made to national aging organizations in response to the 
fiscal year 1992 Discretionary Funds Program Announcement to increase awareness 
of the home and community-based care needs of older persons at risK and to expand 
public awareness of the problems and issues concerning eldercare. These awards 
complement the activities of seven other national aging organizations funded in 
fiscal year 1991. 

NEW STARTS j 

The American Association of Homes for the Elderly (Washington, DC) will estab- 
lish and sustain an Eldercare Initiative designed to increase the availability of sup- 
portive service programs for the low-income elderly residing in and around HUD- 
assisted elderly housing projects. 

The Alzheimer's Disease and Related Disorders Association (Chicago, IL) will un- 
dertake a Community Eldercare Awareness Campaign to demonstrate to community 
organizations and policy and decision makers how the unmet needs for home and 
community based care faced by Alzheimer's Disease victims and their caregivers 
have an adverse affect on the entire community. This project will test the effective- 
ness of local eldercare awareness campaigns to bring about community change for 
at-risk elderly and their families. 

The National Association of Area Agencies on Aging (Washington, DC) will join 
with the Employee Assistance Professional Association (EAPA) to orient client com- 
panies of EAPA to aging issues, to focus employers on eldercare options for older 
worker with dependent relatives, and to facilitate better cooperation between Area 
Agencies on Aging and EAPA chapters. 

The Older Women's League (Washington, DC) will focus national attention on car- 
egivers of family members at risk of losing their independence and on the contribu- 
tions that health care professionals can make in assisting older women in their 
care-giving roles. This project will also provide technical assistance to Project CARE 
coalitions on family caregiving. 

The National Committee for the Prevention of Elder Abuse (Worcester, MA), in 
cooperation with the National Association of Adult Protective Services Administra- 
tors, will promote and enhance the role of State and local eldercare coalitions in 
preventing elder abuse by establishing model elder abuse coalitions in Idaho, Virgin- 
ia, Montana, Texas, and Tennessee. 

The National Association of State Units on Aging (Washington, DC) will stimulate 
greater involvement by print media in the National Eldercare Campaign by improv- 
ing the media's capacity to provide accurate, balanced coverage of aging issues 
which is responsive to the information needs of at-risk older people and their fami- 
lies. 

PROJECTS FUNDED IN FY 1991 

The American Society on Aging (San Francisco, CA) has been targeting its Elder- 
care Campaign advocacy project on those sectors of the community not traditionally 
involved in aging issues, i.e., bankers, architects, grocers, pharmacists, and religious 
groups. 

The National Title VI Directors Association (Tahlequah, OK) has been conducting 
a public awareness campaign on the needs of at-risk American Indian, Alaskan 
Native, and Native Hawaiian elders. A video and presentation packet has been de- 
veloped for Title VI Directors to assist them in conducting presentations at meet- 



99 



ings/conferences between Title VI programs and their local entities. Presentations 
; have begun and have been so successful that more presenters will need to be 
' trained to meet the demand. 

! The American Bar Association (Chicago, ID has concentrated on law-related as- 
I pects of the National Eldercare Campaign with special emphasis on alerting and 
! educating social workers and religious organizations regarding legal issues critical 
to their at-risk elderly clients and congregants. 

The National Caucus and Center on Black Aged (Washington, DC) has designed 
its Eldercare Campaign project to provide training, technical assistance, and infor- 
mation regarding the service needs of at-risk Black elderly to Black sororal and pro- 
fessional organizations in major cities across the Nation. 

The National Hispanic Council on Aging (Washington, DC) is utilizing its chapters 
and affiliate organizations as the "hubs" of a National Eldercare education cam- 
paign in Hispanic communities aimed at youth groups, religious and civil rights or- 
ganizations, schools, and community leaders. 

Save Our Security Education Fund (Washington, DC) is engaged in an advocacy 
effort on behalf of those elderly at risk of losing their independence because of inad- 
equate economic resources. The SOS Education Fund project focuses on educating 
the public about poverty among the elderly and the importance of Supplemental Se- 
curity Income (SSI) for low-income older Americans. 

The Asociacion Nacional Pro Personas Mayores (Los Angeles, CA) has initiated an 
advocacy campaign on behalf of Hispanic elders that emphasizes the involvement of 
Hispanic elected and appointed officials and leaders in business and fraternal orga- 
nizations in addressing the need of Hispanic elders for in-home and community 
based services. 

2. OLDER AMERICANS ACT ELDERCARE VOLUNTEER CORPS 

In April 1991, the U.S. Commissioner on Aging announced the establishment of 
the Eldercare Volunteer Corps. The Corps was established to recognize those per- 
sons who have devoted their time as volunteers in Older Americans Act Programs 
and to encourage the expansion of volunteer efforts. Twenty-eight State Agencies on 
Aging received fiscal year 1991 project awards in support of the Eldercare Volun- 
teer Corps. Federal funds were used to develop and demonstrate improved methods 
for recruiting, training, and retaining volunteers. Many States held recognition 
events for their volunteers, and issued certificates of appreciation especially devel- 
oped for the Corps. 

In fiscal year 1992, 13 new project awards were made to State Agencies on Aging 
to further expand the Older Volunteer Corps. The newly funded State Agencies on 
Aging are expected to bring together key actors to examine current volunteer pro- 
gram activities, to prioritize future volunteer efforts and develop an action plan to 
more effectively recruit, retain, train, and supervise volunteers in Older Americans 
Act Programs, and to begin to implement the plan. Project awards were made to the 
following 13 State Agencies on Aging: 

Alabama Commission on Aging 

California Department of Aging 

District of Columbia Office on Aging 

Florida Department of Elder Affairs 

Indiana Department of Human Services 

Kentucky Division for Aging Services 

Maryland Office on Aging 

Michigan Office of Services to the Aging 

Missouri Division of Aging 

New Hampshire Division of Elderly and Adult Services 

New Mexico State Agency on Aging 

Ohio Department of Aging 

West Virginia Commission on Aging 

3. PROJECT CARE: COMMUNITY ACTION TO REACH THE ELDERLY 

The Commissioner on Aging launched Project CARE (Community Action to Reach 
the Elderly) in May 1991 as a major component of the National Eldercare Cam- 
paign. The goal of Project CARE is to tap the expertise, energy, and experience of 
individuals and organizations and encourage new ideas and approaches for meeting 
the needs of vulnerable, older Americans through formation of state and local com- 
munity coalitions. More than 250 eldercare coalitions were initiated in fiscal year 
1992 with the assistance of grants awarded in fiscal year 1991 to 16 Area Agencies 
on Aging and 52 State Agencies on Aging. 



100 



On an optional basis, about 30 States started statewide coalitions. The statewide 1 
coalitions were formed to support the work of the community coalitions. State coali- 
tions provide a mechanism for building widespread public awareness about the 
needs of older persons. They also provide a way to focus attention on the need for f 
State level, comprehensive strategies to help vulnerable older persons. 

The community coalitions are implementing practical, immediate service projects 
to help vulnerable older persons. Each is working to broaden the base of support for ] 
eldercare concerns by empowering local community leadership to take greater re- 
sponsibility for their vulnerable older persons. The coalitions include a significant i 
number of nonaging organizations which traditionally have not been involved with i 
aging concerns. 

Project CARE coordinators from local coalitions, Area Agencies on Aging, and 
State Agencies on Aging participated in two orientation and training events spon- 
sored by the Administration on Aging. The first was a National Forum on Eldercare 
held in Washington, D.C. in December 1991. The second was a training session on 
coalition development held in each Administration on Aging region during the 
Spring of 1992. The coalitions were challenged to focus on at least one need and 
implement a service project to meet that need. 

During their first year, the local coalitions were engaged in problem solving and 
the infusion of new ideas, capacities and resources as part of community solutions 
for meeting the needs of the vulnerable elderly. In fiscal year 1992, AoA refunded 
the projects awarded in fiscal year 1991 to continue support of existing coalitions for 
a second year. AoA provided additional funds for expansion which is expected to 
result in the formation of 600 new community coalitions. Highlights from the first 
year include: 

Virtually all of the coalitions had organized and met at least once. 
Approximately 81 percent had identified a target population. 
Approximately 80 percent had selected a priority service need. 
An estimated 83 percent had started some level of service planning and 67 
percent had started or completed a service project. 

4. NATIONAL ELDERCARE CAMPAIGN MEDIA CONTRACT 

During 1992, Global Exchange Inc. worked with AoA to develop a series of prod- 
ucts to heighten public awareness about eldercare issues. These products have 
proven useful to the organizations participating in the campaign and have helped 
them to conduct their own public awareness campaigns at the state and local level. 

The products developed include the campaign theme — Community Action Begins 
With You: Help Older Americans Help Themselves, a poster, a public/press infor- 
mation kit, three issues of a new magazine called Eldercare Today, a National El- 
dercare Campaign brochure, a brochure highlighting the activities of national orga- 
nizations, several articles for publication in the press about important eldercare 
issues, a radio Public Service Announcement on National Caregiver Week, an arti- 
cle for publication in 300 religious publications, a video and a TV Public Service 
Announcement (PSA) on Project CARE, and a series of traveling exhibits for use at 
meetings and conferences. 

The efforts of AoA and Global Exchange at the national level were supported by 
media campaigns conducted at the state and local level. State and local entities de- 
veloped news articles, videos, radio and TV PSAs and special events to promote 
public understanding and support for eldercare programs and issues. 

5. ELDERCARE CONNECTIONS 

AoA funded a grant in fiscal year 1992 to the National Association of State Units 
on Aging to provide Campaign organizations access to a comprehensive repository of 
information concerning the National Eldercare Campaign. Known as "Eldercare 
Connections", the services provided include: 

Summary information about products produced for the Campaign. 
Publication and distribution of a bi-monthly update of all produces received. 
Maintaining a computerized bulletin board for quick access to information in 
the database. 

Publication and distribution of a Calendar of Events of important eldercare 
meetings around the country. 

6. NATIONAL CENTER ON COALITION BUILDING 

Through support provided by AoA, the National Association of Area Agencies on 
Aging established the National Resource Center on Coalition Building (NRC). The 
purpose of the NRC is to provide training, technical assistance and support for State 



101 

and Project CARE community coalitions participating in the National Eldercare 
ij Campaign. 

During 1992 the NRC developed a training program to enhance the capacity of 
Project CARE community coalitions to develop effective coalitions. A core group of 
consultants were trained as trainers. Training sessions were held in each of the 10 
federal regions for State, Area Agency on Aging and community coalition staff. The 
NRC also collected information about effective coalition building techniques and 
synthesized and disseminated these products to participating coalitions. The NRC 
established a toll free telephone number to provide assistance on a variety of coali- 
tion building topics to community coalitions. 

NRC also developed resource materials on coalition building and disseminated 
them to all State, Area Agencies on Aging and community coalitions. 

7. NATIONAL ELDERCARE INSTITUTES 

As part of the National Eldercare Campaign, the Administration on Aging has 
supported a number of specialized National Eldercare Institutes located in national 
organizations and academic institutions. In fiscal year 1991, 12 National Eldercare 
Institutes were awarded project grants under the terms of a three-year cooperative 
agreement. In 1992, an additional award was made to establish a second National 
Eldercare Institute in the area of Long Term Care. Each Institute focuses on a criti- 
cal substantive area relevant to improving eldercare services, both in the home and 
community. Each Institute addresses issues vitally important to those older persons 
struggling to maintain their self-sufficiency. Working in close collaboration with el- 
dercare coalitions across the Nation, the National Eldercare Institutes also under- 
take a variety of activities designed to support and assist State and Area Agencies 
on Aging in carrying out their missions as planners and coordinators of aging serv- 
ices within their jurisdictions. 

a. Long-Term Care 

Two National Eldercare Institutes on Long Term Care are currently supported on 
the basis of the competition held in fiscal year 1991, although one was first deferred 
and then later funded in fiscal year 1992. 

(1) The National Eldercare Institute on Long Term Care, conducted by the Nation- 
al Association of State Units on Aging (Washington, D.C.) in collaboration with 
Brandeis University (Waltham, Massachusetts), supports the National Eldercare 
Campaign by being a resource on home and community-based care for the at-risk 
elderly population. The Institute enhances the capacity of Eldercare coalitions to 
identify issues relevant to long term care that need to be addressed in their commu- 
nities through consultation, knowledge synthesis, training, and technical assistance. 
These activities are assisting community and State coalitions to implement commu- 
nity care agendas and to promote adoption of these agendas by segments of society 
that can build a broad base of support for Eldercare programs and services. In addi- 
tion, the Institute supports the community long term care agenda of the Eldercare 
Campaign by developing informative resource materials. 

During the first year of operation, the Institute produced a number of high qual- 
ity products including issue briefs, reports and guides designed to provide important 
information to Project CARE coalitions to help them plan, develop, and implement 
community based service systems. In addition, the Institute has provided extensive 
telephone technical assistance, on-site technical assistance, and training to local and 
state coalitions and others. In its second year, the Institute will build upon its ac- 
complishments in Year 1, producing additional information materials, action guides, 
and reports; providing technical assistance and training; and conducting teleconfer- 
ences and policy forums. 

(2) The National Eldercare Institute on Long Term Care and Alzheimer's Disease 
at the Suncoast Gerontology Center, University of South Florida, was funded May 1, 
1992. This Institute has designed activities that will support the National Eldercare 
Campaign with current, practical information on critical long term care issues, espe- 
cially Alzheimer's Disease. Other major areas the Institute is focusing on include 
home and community based model long term care programs and services, and care- 
givers and caregiving. The Lnstitute has produced several informative briefs and a 
guide for coalition building at the local level. It has also provided telephone techni- 
cal assistance and conducted a number of statewide and national training sessions. 



102 



b. Elder Abuse and State Ombudsman Services 

The National Eldercare Institute on Elder Abuse and State Long Term Care Om- 
budsman Services is conducted by the National Association of State Units on Aging \ 
(Washington, D.C.) in collaboration with the American Public Welfare Association [ 
(Washington, D.C.) and the National Citizens Coalition for Nursing Home Reform \ 
(Washington, D.C). The purpose of the Institute is to strengthen community, State [ 
and national efforts to combat elder abuse in domestic and institutional settings and 
to support the development and effective operation of Long Term Care Ombudsman 
Programs supported under Title HI of the Older Americans Act. 

In Year One, the Institute increased awareness of the problem among the public 
and key professionals by (1) providing expert information to local and national jour- 
nalists and broadcasters and professional groups, including the Advisory Committee 
of the American Medical Association responsible for development of guidelines for 
use by physicians in diagnosing and treating elder abuse patients; (2) developing and 
disseminating educational materials such as "Elder Abuse: Questions and Answers," 
"Fact Sheets on Domestic Elder Abuse and Institutional Elder Abuse and Ombuds- 
man Services;" and (3) participating in meetings including the National Association 
of State Adult Protective Service Administrators, American Medical Directors, and 
the Alzheimer's Association. 

The Institute provided training and technical assistance via (1) conferences and i 
workshops such as the 1992 National Training Conference for State Long Term Care 
Ombudsman and the 1992 Adult Protective Services Conference in Texas; (2) practi- 
cal guides such as "A Guide to Program Evaluation for the State Long Term Care ' 
Ombudsman Program", updates on nurse aide training and quality of care, and pa- | 
tient self-determination for the "Ombudsman Desk Reference," updates to the "Om- 
budsman Desk Reference," and an addendum for the "Comprehensive Curriculum" 
on abuse and effective ways for the ombudsman to participate in the survey process; 
(3) disseminated information on exemplary programs and best practice models to 
improve elder abuse and ombudsman services, and (4) initiating the gathering of in- 
formation on the training and technical assistance needs of key professionals work- 
ing with elder abuse. 

In its second year of operation, the Institute will continue providing support ac- 
tivities to the various components of the Eldercare Campaign. The Institute will 
focus on assessing the training and technical assistance needs of key elder abuse 
professionals; conducting an elder abuse public education campaign; improving 
knowledge about elder abuse and ombudsman services by providing training and 
technical assistance to professionals and community groups at conferences via work- 
shops and panel discussions; and publishing research notes, updates of elder abuse 
state data reports and state laws, and an analysis of nurse aide registries in three to 
five states. 

c. Older Women 

The National Eldercare Institute on Older Women will be directed by the National i 
Council of Negro Women (Washington, D.C). The Institute is designed to address 
issues affecting diverse populations of older women with special attention to those 
most at risk. 

During Year One, the institute developed the following products in collaboration 
with the Older Women's League: "A Profile of Older Women," "Older Women as 
Caregivers: Responsive Community Programs," and a "Caregiving Best Practice | 
Profile." Additionally, Brandeis University developed three briefing papers: "Income 
Status of Older Women: A Briefing Paper for the National Eldercare Institute on 
Older Women," "Caregiving: Challenging Complexity," and "Health and Access to 
Health Care: The Special Challenge of Older Women." The institute conducted 
training and technical assistance at a variety of conferences, symposia, forums and 
workshops. A major focus of the institute was to serve as a catalyst and encourage 
national women's organizations to adopt an older women's issues agenda in their 
national and local program activities. 

The Institute will continue to be a focal point for collaboration among national j 
women's organizations and national aging organizations on issues and concerns of 
older women at risk. In addition to the development of model and best practice ma- 
terial, increasing public awareness, and expanding the knowledge base, a major pri- 
ority for year two will be the convening of a national conference. This conference 
will provide a setting in which current and future trends for the provision of elder- 
care services to older women can be analyzed and considered by all types of advo- 
cates for the well-being of older women. 



103 



d. Multipurpose Senior Centers and Community Focal Points 

The National Eldercare Institute on Multipurpose Centers and Community Focal 
Points is conducted through the National Council on Aging (Washington, D.C.). The 
Institute's mission is to encourage communities to develop senior centers to serve at- 
I risk older people in their home as well as in congregate facilities, and, conversely, to 
encourage existing senior centers to expand their services for at-risk elderly and in- 
crease their linkages to non-traditional community groups. 

During Year One, the Institute developed and published a quarterly newsletter; 
trained people in the utilization of Senior Center Standards; created a Speakers 
Bureau, now totalling over 150 experts who have started to offer telephone assist- 
ance to coalitions and senior centers; and distributed materials on eldercare and 
community focal points to over 15,000 Senior Centers. The Institute developed a syn- 
thesis of research on senior centers which will result in an agenda for practice-ori- 
ented research. It conducted major presentations on senior centers at national meet- 
ings and produced a video describing multipurpose senior centers, directed to non- 
gerontological audiences. The video emphasizes the important role of volunteers and 
illustrates ways that religious institutions, businesses, etc. can become involved with 
their local center. 

During Year Two, the Institute will develop guides on funding resources, pro- 
gramming for at-risk-populations, development of facilities, and program evaluation. 
These topics will be the subject of a series of audio teleconferences on meeting the 
emerging needs of Eldercare Coalitions. The Institute will continue to publish a 
quarterly bulletin, to train trainers in the utilization of Senior Center Standards, 
and to expand its Speakers Bureau. Increased emphasis will be placed on helping 
the State Units on Aging and the Area Agencies on Aging to be resources to those 
Eldercare Coalitions focusing on multipurpose senior center issues. A national com- 
petition highlighting studies of best practices in serving at-risk elderly will be held. 
Four challenge grants will be provided to researchers to design and conduct senior 
center program evaluations and other needed studies. 

e. Transportation 

The National Eldercare Institute on Transportation is conducted by the Communi- 
ty Transportation Association of America, (CTAA, Washington, DC) in collaboration 
with the National Association of Area Agencies on Aging (NAAA, Washington, DC), 
the National Center and Caucus on Black Aged (NCBA, Washington, DC) and the 
National Council on the Aging (NCOA, Washington, DC). The goals of the Institute 
are to increase public awareness and commitment to the transportation and mobili- 
ty needs of at-risk older persons; to serve as a resource institute on aging and trans- 
portation/mobility issues to the National Eldercare Campaign and its Project CARE 
coalitions; to gather, analyze and disseminate data on aging and transportation 
issues; and to provide training and technical assistance on aging and transportation 
issues. 

In Year One, the Institute developed educational materials for improving trans- 
portation and increasing public awareness of its role in enhancing and maintaining 
the quality of life and maintaining the dignity and independence of the elderly. 
Written products were prepared on (1) "Understanding the Basics of Community 
Transportation", (2) "The Americans With Disabilities Act and Aging Transit Serv- 
ices", (3) "Coordinating Transportation in Your Community", (4) "Best Practice Pro- 
files for Model Transportation Systems Serving the Elderly" and (5) "Transportation 
Focus Group Report" on practitioners and elderly issues and concerns. Several 
workshops and training sessions were held where discussion took place on transpor- 
tation issues and policies, coordination, ADA, and the National Eldercare Campaign, 
to name a few. A national toll-free transit hotline was also set up to answer ques- 
tions on aging and transit issues. 

In Year Two, the Institute will continue to develop technical assistance issue 
briefs, best practice profiles, articles and educational pieces. Issue briefs are pro- 
posed on such topics as resource development, insurance for specialized transporta- 
tion including liability issues as they affect older volunteers involved in specialized 
transportation, and contracting procedures for transportation. Roundtables, infor- 
mation sharing and efforts to heighten the visibility of the Institute and the Nation- 
al Eldercare Campaign will continue. 

f. Housing and Supportive Services 

The National Eldercare Institute on Housing and Supportive Services is operated 
by the University of Southern California (Los Angeles, California) in collaboration 



104 



with the National Association of Area Agencies on Aging (Washington, DC) and the 
Federal National Mortgage Association (Washington, DC). The Institute is continu- 
ing to mobilize public, private and voluntary sector resources to better link elderly 
housing with supportive services and increase supportive housing options for the at- 
risk elderly population. 

The Institute has developed a variety of resource guides, fact sheets, briefing 
papers and reports on strategies to create housing coalitions and successful housing 
programs for the at-risk elderly. In addition to giving technical assistance to the 
State and Area Agencies on Aging and Eldercare coalitions, the Institute will con- 
tinue to involve traditional aging and housing organizations and new groups in 
public /private partnerships as one approach to raising public awareness of the need 
and ways to expand housing and support service options. 

Information has been synthesized on recent developments in housing programs 
that best serve at-risk elderly, including homesharing, accessory units, reverse mort- 
gages, home modification and repair, assisted housing, and the section 202 housing 
program administered by the Department of Housing and Urban Development. In 
addition, the Institute has held four teleconferences and numerous presentations at 
national aging organization meetings and other gathering focused on the elderly's 
housing and service needs. 

g. Nutrition Services 

The National Eldercare Institute on Nutrition is a joint effort conducted by the 
National Association of Nutrition and Aging Services Programs (Grand Rapids, MI) 
in collaboration with the National Association of Meals Programs (Washington, DC), 
the National Association of State Units on Aging (Washington, DC), the National 
Meals on Wheels Foundation (Washington, DC), the DuPont Corporation (Wilming- 
ton, DE), Ross Laboratories (Columbus, OH) and the Nestle Corporation (Washing- 
ton, DC). The Institute is focusing on nutritional issues of the at-risk elderly and 
their impact on improving nutritional services and product development in commu- 
nity settings. 

The Institute, in its first year, developed and began disseminating educational and 
public information materials which give a basic understanding of the nutrition 
needs of at-risk older persons, the relationships between nutrition and health, the 
types of nutrition services that are effective and efficient, and strategies to develop 
new services or enhance existing ones. Through its private sector collaborators, the 
Institute has been providing a link between community nutrition services and the 
food and packaging industry which will enable both to better serve the needs and 
preferences of the at-risk population. 

In the second year of operation, the Institute will sponsor two Futures Forums. 
Together with the two forums held in the first year, this series is aimed at establish- 
ing a strategic plan for aging nutrition services for the rest of the decade. In addi- 
tion, with the generous support of the Nestle Corporation, the Institute will co-spon- 
sor a scientific conference for nutrition professionals and providers in the Spring of 
1993. The Institute will release several issue papers on matters of relevance to the 
aging network and will provide technical assistance through a series of teleconfer- 
ences for both State and Area Agency staff and nutrition providers. 

h. Human Resource Development 

The National Eldercare Institute for Human Resource Development is operated by 
the Brookdale Center on Aging, Hunter College of the City of New York in collabo- 
ration with the American Society on Aging in San Francisco, California. The pur- 
pose of the Institute is to help State Units on Aging, Area Agencies on Aging, and 
eldercare coalitions promote the most effective use of human resources in programs 
serving the elderly. 

Among the Institute's Year One accomplishments were the provision of training 
and technical assistance in such areas as training techniques, staff recognition, and 
team building and management; solicitation, evaluation, and dissemination of best 
practice in human resource development for use in aging programs; presentation of 
human resource best practice awards to exemplary staff development programs in 
three health and long term care organizations; and preparation and dissemination 
of initial Institute training calendars and newsletters. 

In Year Two the Institute will continue and expand these Year One activities. It 
will also initiate a manpower analysis of personnel in the field of aging and work 
with several national non-profit and business organizations to secure training offer- 
ings and human resource best practice information of interest to the aging network. 



105 



The institute will publish a new human resource bulletin that addresses timely 
workforce issues facing those involved in the field of aging. 

i. Health Promotion 

The National Eldercare Institute on Health Promotion is conducted by the Ameri- 
can Association of Retired Persons (Washington, DC) in collaboration with Meharry 
Medical College (Nashville, TN). The purpose of the Institute is to encourage 
healthy behaviors among older persons and their caregivers and serve as a knowl- 
edge base and program resource on health promotion and disease and disability pre- 
vention for vulnerable older persons. The Institute collects and disseminates infor- 
mation about successful health promotion program models which assist older per- 
sons in maintaining their well-being and independence and information on overcom- 
ing barriers to reaching low income minority populations. Research findings and 
best practice information on health promotion will be incorporated into technical 
assistance guides and training materials for use in conjunction with the work of na- 
tional, State, and community Eldercare Coalitions and disseminated to health care 
networks. 

During the second year, the Institute will develop models of technical assistance 
to Eldercare Coalitions working through AoA's Regional Offices which will, in turn, 
work with State and Area Agencies. In addition, the Institute will develop publica- 
tions on such topics as urinary incontinence and preventions of falls. Their quarter- 
ly newsletter, "Perspectives in Health Promotion and Aging" will be distributed to 
the 17,000 names on the mailing list. A Federal Interagency Taskforce on Health 
Promotion is also being formed with staff support from the Institute and in collabo- 
ration with the Public Health Service and the National Institute on Aging. Meharry 
Medical College will continue to hold their monthly outreach seminars on health 
promotion topics. 

j. Income Security 

The National Eldercare Institute on Income Security is administered by Families 
USA, Foundation, Inc. (Washington, D.C.). The Institute focuses on the living stand- 
ards of the low-income elderly and their access to benefits and entitlement pro- 
grams that meet their needs. It conducts analyses on selected topics related to 
income security to identify key factors that can serve as the basis for a public 
awareness campaign and stimulate interest among Eldercare Coalitions, such as ex- 
amination of the elderly poverty rate, a study of the "Medicaid Gap" as it relates to 
coverage of health services and nursing home care, the affordability of long term 
care insurance, and the proportion of out-of-pocket health costs not being paid by 
Medicare and Medicaid. The Institute works with other interested organizations to 
promote outreach activities to make low income older persons aware of their possi- 
ble eligibility as "Qualified Medicare Beneficiaries". Under this program, Medicaid 
pays their Medicare premiums and deductibles. The Institute also promotes public 
education to increase participation of low-income elderly in the Supplementary Se- 
curity Income (SSI) program. 

During fiscal year 1992, the Institute will continue to focus on the provision of 
information to potential and current SSI eligible older persons. It will provide infor- 
mation on benefits and application procedures and various types of coalition activi- 
ties that have been organized and conducted by them. It will continue to hold press 
conferences on research reports and findings concerning prescription drug costs and 
national enrollment efforts aimed at SSI eligible individuals. The Institute will con- 
duct a national health survey on elderly health care and benefits. 

k. Employment and Volunteerism 

The National Eldercare Institute on Employment and Volunteerism is conducted 
by the Center on Aging, University of Maryland (College Park, Maryland) in col- 
laboration with the National Council on the Aging (Washington, D.C.), the National 
Retiree Volunteer Center (Minneapolis, Minnesota), and the American Association 
of Retired Persons (Washington, D.C.). The Institute's overall mission is to improve 
the quality of life for older persons by enhancing and increasing volunteer and em- 
ployment opportunities. The Institute operates a clearinghouse on volunteerism de- 
signed to synthesize knowledge and information on curriculum and training models, 
effective programming, and policy analysis which can enhance the effective use of 
volunteers in eldercare service organizations. 

During the first year, the Institute, at the request of the Administration on 
Aging, concentrated solely on volunteerism. In addition to making presentations at 



106 



the major aging conferences in 1991, the Institute sponsored a workshop on inter- 
generational volunteerism at the National Points of Light Conference in June. It 
produced a number of information and technical assistance materials, including 
seven resource briefs and monographs on topics relating to volunteerism, an anno- 
tated bibliography, and a training video and manual on retaining volunteers. The 
Institute conducted several surveys including one of national voluntary organiza- 
tions and another of over 200 Volunteer Action Centers and ACTION State Direc- 
tors. It also sponsored a two-day cluster meeting for AoA/ ACTION Senior Compan- 
ion Program grantees in June. The meeting provided program directors with strate- 
gies for developing resources by engaging the larger community in the program's 
mission. 

During the second year, the Institute will continue its focus on volunteerism and 
begin work in the area of employment. The Institute will again make presentations 
at all the major national and regional aging conferences, coordinate the Volunteer 
Track for the 1993 American Society on Aging conference and convene a National 
Roundtable on the Future of Volunteerism and Aging. It will produce and dissemi- 
nate several resource briefs, training modules and technical assistance papers. The 
Institute will also establish an older worker program clearinghouse and resource 
file. A National Symposium on New Roles for Older Persons is planned for 1992 to 
increase issues related to an aging workforce. 

I. Business and Aging 

The National Eldercare Institute on Business and Aging is conducted by the 
Washington Business Group on Health (Washington, DC) in collaboration with the 
American Society on Aging (San Francisco, CA). During its first year, the Institute 
successfully developed and disseminated many useful products and programs to 
business organizations, foundations, and the aging network, including Project Care 
Coalitions. These included several publications, a regular newsletter, fact sheets and 
a board game which teaches the steps in developing public/private partnerships. 
The Institute also conducted seminars at the major national aging conferences on 
such topics as public/private partnerships and working with the business communi- 
ty on eldercare programs. In addition, the Institute has gradually increased its role 
in providing technical assistance through teleconferences, on-site presentations and 
telephone consultation. 

In the coming year the Institute plans additional technical assistance materials 
on collaboration with the business community and foundations, a quarterly newslet- 
ter, conference seminars and telephone technical assistance. The Institute will also 
implement a Business and Aging Speakers Bureau, special topic teleconferences, a 
Media Advisory Committee, a Congressional Briefing on business and aging issues 
and provide assistance to AoA with the 1993 Business and Aging Leadership 
Awards. 

C. Other Title IV Initiatives 

Title IV of the Older Americans Act includes language in its provisions which 
direct the agency and the Commissioner on Aging to support, or consider support- 
ing, activities which improve the quality of personnel in the field of aging; expand 
access to services with special attention to the most vulnerable elderly; disseminate 
information to professionals, the elderly, and the lay public; and increase knowledge 
and the design and implementation of effective services and activities which im- 
prove the well-being of older Americans. More than 100 grants and contracts which 
supported these broad purposes were awarded, continued, or active during 1992. 
They are described in the following pages of this report. 

1. DISSEMINATION AND UTILIZATION 

Title IV of the Older Americans Act calls upon AoA to support a broad range of 
research, demonstration, and training projects to improve the well being of older 
persons. In order for these efforts to be effective, it is critical that the information 
developed by Title IV projects be disseniinated as widely as possible. In recent years 
there has been considerable interest in this issue both in the field of aging and in 
Congress. In response to this interest, AoA has increased its efforts to insure that 
up-to-date information is as widely available as possible to those involved in making 
this country a better place in which to age. 



107 



a. Division of Dissemination and Utilization 

In August, 1992, AoA established a Division of Dissemination and Utilization 
(DDU) within the Office of Program Development. This Division is responsible for 
implementing and managing a new system for the collection, analysis and wide- 
spread dissemination of knowledge developed about issues of concern to older Amer- 
icans by title IV grantees. The audience for this information includes State and 
Area Agencies on Aging, other professionals in the field of aging and other agencies 
and organizations concerned about America's aging population and older persons. 
DDU is developing activities designed to capitalize on the resources available to the 
Administration on Aging to (1) expand its capacity for transmitting information in a 
timely and useful manner; (2) encourage maximum utilization of best practice pro- 
gram models and research; and (3) encourage maximum interaction and exchange of 
the most recent information and program expertise. 

b. National Eldercare Dissemination Center 

Grant and contract activities supported by the Older Americans Act Title IV Dis- 
cretionary Fund Program have produced a wide range of usable findings and prod- 
ucts. For these program results to be appropriately utilized AoA, in fiscal year 1991, 
supported an initiative that would expand the dissemination capabilities of AoA and 
AoA's current and future grantees. This initiative established the "National Elder- 
care Dissemination Center" at the National Association of State Units on Aging in 
Washington, DC. Through a cooperative agreement, the Center, working in close col- 
laboration with AoA, promotes more effective dissemination of findings and prod- 
ucts to a large number of potential users. 

The Center engages in a number of activities designed to promote the dissemina- 
tion of Title IV project findings and products. These activities include: (1) developing 
a database that contains information on Title IV program projects and products and 
retrieving this information upon request; (2) selecting some of the most promising 
projects and providing assistance in disseminating their results to Eldercare coali- 
tions, aging network agencies, national aging organizations, and others; (3) provid- 
ing technical assistance to Title IV grantees to help them expand their dissemina- 
tion activities; (4) publishing a yearly-compendium of Title IV program products; 
and (5) developing a range of general dissemination channels which can be used by 
Title IV grantees. 

2. PREPARATION FOR AGING SOCIETY 

One of the most dramatic changes in our nation is the rapid aging of our popula- 
tion. Every segment of our society will be influenced by the needs, resources, and 
expertise of our older citizens, and will need to respond appropriately. To meet 
today's challenges, and those in the future, the Administration on Aging continues 
to support education and public information activities which keep the American 
public and its leadership informed of the nature and implications of this demo- 
graphic revolution. 

a. National Academy on Aging 

In 1991, the Administration on Aging entered into a three-year Cooperative 
Agreement with the Maxwell School of Citizenship and Public Affairs at Syracuse 
University to establish and carry out the activities of the National Academy on 
Aging. Howard University and the National Council on the Aging, Inc. are also part 
of the National Academy on Aging with responsibility, respectively, for the areas of 
minority aging and information dissemination to the field of aging and the aging 
network. The Academy also has an office located in Washington, D.C. 

The objectives and tasks of the Academy are to: (1) Promote greater national lead- 
ership on aging issues and the development of effective strategies to meet the chal- 
lenges of an aging society; (2) convene leaders from the major sectors of society to 
identify and debate emerging trends and issues in aging; and (3) encourage discus- 
sion and discourse on aging issues between aging and non-aging leaders in Ameri- 
can society. 

In its role as an impartial national forum for policy analysis and debate on the 
major policy issues of an aging society, the Academy has a mandate from AoA to 
conduct executive seminars and conferences for national leaders on matters of criti- 
cal importance to an aging society. Related tasks of the Academy include policy re- 
search and analysis, the commissioning of issue papers, the preparation and publica- 
tion of reports, and the dissemination of conference/seminar proceedings. 



108 



In its first year, the Academy focused on the issue of income security. An execu- 
tive seminar on Poverty and Income Security was held in early July, followed by an 
examination of Pension Safety, Equity, and Adequacy on October 27-28. A round 
table session on Income Security and Aging is projected for mid-March 1993. 

The Academy proposes to consider the policy issue of Long Term Care in 1993, 
with priority emphases on in-home and community-based services, the Medicare/ 
Medicaid system, and the pivotal place of long term care in the current debate over 
health care reform. With the choice of long term care as the focus for 1993, the 
Academy will maintain its principal role as a national forum on policy issues of 
pressing importance to the older population while bringing it closer to the concerns 
of the Aging Network and of practitioners. 

b. National Leadership Institute on Aging 

The National Leadership Institute on Aging directed by the University of Colora- 
do in Denver provides quality leadership development opportunities to executives in 
the aging network in order to improve their leadership capabilities. These execu- 
tives include representatives from State and Area Agencies on Aging, tribal units, 
national aging organizations, and other national organizations and private and non- 
profit organizations that have responsibility for developing and implementing serv- 
ice systems for older persons and their caregivers. The Institute increases the capac- 
ity of these individuals to better design and deliver strategic and innovative services 
and stimulate changes in the system in order to enhance family and community- 
based care. 

Residential leadership programs are the primary method which the Institute uses 
to meet its objectives. These intensive programs, led by expert faculty, are generally 
10 days in length. The Institute has, thus far, implemented 10 programs, with addi- 
tional ones planned for the future. Participants have come from almost every State 
in the Union. The success of these programs has been well documented and the In- 
stitute has achieved national recognition. In addition, the Institute provides techni- 
cal assistance and consultation to aging network agencies and others, nationwide, 
relevant to the development of plans which can enhance the leadership skills and 
abilities of their executives. 

c. Collaboration With the National Institute on Aging 

In 1992 the Administration on Aging and the National Institute on Aging (NLA) 
signed a Memorandum of Understanding to further advance their joint efforts to 
help maintain the independence of the nation's elderly, to improve their health and 
well-being, and to enhance their quality of life. 

The new Memorandum of Understanding is intended to cover AoA/NIA joint pri- 
orities and collaborative activities through at least fiscal year 1993. The priority 
areas are: (1) Racial/Ethnic Minority Elderly, (2) Health Promotion and Disease Pre- 
vention, and (3) Elder Abuse. Implementation of the broad objectives and priority 
areas of the Memorandum of Understanding will be accomplished through specific 
Interagency Agreements, which are subject to approval by the Commissioner on 
Aging and the Director of NIA. 

The Commissioner on Aging is an ex-officio a member of the Task Force on Aging 
Research, which is legislatively mandated to make recommendations to the Secre- 
tary of the Department of Health and Human Services regarding directions in aging 
research; to prioritize research needs; and to develop a budget to carry out the re- 
search. The Director of the National Institute on Aging has been designated by the 
Secretary as the Chair of the Task Force. 

AoA staff have served as Chairpersons and members of a number of the Task 
Force subcommittees. The subcommittees have reviewed recommendations from 
over 70 Federal government aging research policy and planning reports issued 
during the last 12 years. An interim report, collating and summarizing these vol- 
umes of recommendations, has been completed and distributed to the Task Force in 
preparation for its deliberations and action on a proposed Federal • aging research 
agenda which will be submitted to the Secretary in 1993. 

d. Coming of Age in America 

AoA provided grant support in fiscal year 1990 to the Coming of Age in America 
Association (Seattle, Washington) for the planning phase of Coming of Age in Amer- 
ica, a national traveling exhibit that celebrates aging. Preliminary plans for the ex- 
hibit have been completed with funding currently being sought from government, 
business, and foundation sources for implementation. When completed, the exhibit, 



109 



developed in association with the Smithsonian Institution and the American Asso- 
ciation of Retired Persons, will visit shopping centers, libraries, museums and com- 
munity centers across the country. The project will help build a positive image of 
aging, provide information for younger people that will help them age positively, 
and give older people information that will help them access local services, helping 
them to remain as independent as possible. 

e. Public Elementary and Secondary Education 

AoA funded three State Education Agencies in Fiscal Year 1990 to integrate con- 
cepts about aging into the public school curriculum. The objectives included develop- 
ing materials, designing activities using older volunteers, and training teachers to 
incorporate information about aging into the curricula of elementary and secondary 
school programs. These projects completed their activities in 1992 and are actively 
disseminating materials developed during their grants: 

The Connecticut State Department of Education (Hartford, Connecticut) pro- 
duced a series of guides for secondary school teachers in health, home econom- 
ics, language arts, and social studies and produced resource guides for school 
administrators and guidance counselors. 

The Missouri Department of Elementary and Secondary Education (Jefferson 
City) in collaboration with the Center for the Study of Aging at the University 
of Missouri (Jefferson City) prepared aging resource materials for use in grades 
three, seven and ten and an annotated bibliography on children's books that 
convey positive images of aging. 

The Mississippi State Department of Education (Jackson), in cooperation with 
the University of Mississippi Geriatric Education Center, developed teaching 
modules for grades seven to twelve as an addendum to the new Mississippi 
Comprehensive Health Curriculum for Secondary Schools which teaches funda- 
mental concepts of aging. 

3. MULTIDISCIPLINARY CENTERS AT HISTORICALLY BLACK COLLEGES AND UNIVERSITIES 

The Administration on Aging initiated support, in fiscal year 1992, to establish 
Multidisciplinary Centers of Gerontology at Historically Black Colleges and Univer- 
sities (HCBU's). Preference was given to institutions that had not previously had an 
organized campus unit or program focus on aging. This support responds to Execu- 
tive Order No. 12677. The Executive Order encourages the Department of Health 
and Human Services to support the involvement of HCBU's in the health and social 
service concerns of low income, socially disadvantaged and minority older persons 
by initiating efforts to increase the number of minorities trained in the health, 
allied health and supportive services professions. 

The Centers are asked to assist AoA in the execution of its mandated responsibil- 
ities as they relate to improving the quality of life for the minority elderly, especial- 
ly the Black elderly, including collaboration with the National Network on Aging 
and participation in the National Eldercare Campaign. 

The Administration on Aging's Historically Black College and University Initia- 
tive awarded three project grants in late fiscal year 1992. The three-year projects 
were selected from 25 proposals submitted in response to a national proposal compe- 
tition sent to the more than 100 recognized Historically Black Colleges and Univer- 
sities established before 1962. The Administration on Aging expects that the three 
Centers will be self-sufficient by the end of the third year. 
The Multidisciplinary Centers are: 

Howard University (Washington, DC) is establishing its Multidisciplinary 
Center of Gerontology in the School of Social Work. Center efforts will focus on 
education, training, curriculum development, research, information dissemina- 
tion and development of a repository of information on minority elders, espe- 
cially the African American Elderly. The Center's first year activities will con- 
centrate on education and training. During years two and three, a research 
agenda will be developed and a campaign for sustained support of the Center's 
operation initiated. Anticipated products include models for a multidisciplinary 
center on gerontology at an Historically Black College or University; curricula 
for professionals and service providers; a directory of gerontological courses and 
curricula offered at Washington area colleges and universities, public service 
announcements and a research agenda for HBCUs. 

Lincoln University (Philadelphia, PA) is establishing a Multidisciplinary 
Center of Gerontology to be coordinated through the Master of Human Services 
Program. Center activities will be concentrated in the areas of: (1) gerontology 
faculty and curriculum development; (2) development of an advanced certificate 



110 



in gerontology; (3) establishment of gerontology and geriatrics continuing educa- 
tion institutes; (4) research in gerontology and geriatrics; and (5) restructuring 
the undergraduate certificate in gerontology as a formal undergraduate pro- 
gram. The Center plans to serve a resource center for professionals and aging 
service providers in the Mid-Atlantic region by providing training and technical 
assistance and disseminating information. Anticipated products include a model 
for a multidisciplinary center on gerontology at an HBCU and curricula for pro- 
fessionals and services providers and other technical assistance materials. 

Morehouse School of Medicine (Atlanta, GA) is establishing a Multidiscipli- 
nary Center of Gerontology that will serve as Coordinator of a Consortium of 
HBCUs in Georgia. Particular attention will be paid to the needs of the rural 
elderly. Center, activities will be concentrated on: (1) developing an infrastruc- 
ture for interdisciplinary collaborative efforts; (2) faculty development in cur- 
riculum and clinical skills; (3) continuing education with a rural focus; (4) stim- 
ulating research on minority aging issues to provide technical assistance to 
policy makers and service producers; and (5) establishing a clearinghouse and 
resource center. Anticipated products include a model consortium approach for 
establishing a multidisciplinary center on gerontology at an HBCU and curricu- 
la for professionals and services providers that focus on the rural minority el- 
derly and other technical assistance materials. 

4. FY 1992 DISCRETIONARY FUNDS PROGRAM ANNOUNCEMENT 

The majority of new project grant awards are made as a result of a competitive 
review of applications submitted under an annual AoA Discretionary Funds Pro- 
gram Announcement. The announcement, published in the Federal Register, in- 
cludes a range of priority areas which are responsive to the broad purposes of the 
Older Americans Act, the goals of the National Eldercare Campaign, and specific 
mandates identified in Title IV, such as promoting the continued strengthening of 
comprehensive and coordinate community service systems and making them accessi- 
ble and acceptable to older persons. 

The fiscal year 1992 Discretionary Funds Program Announcement was published 
on April 30, 1992, with an application deadline of June 30, 1992. Over 200 eligible 
applications were received for competition in eight priority areas. A review of appli- 
cations by panels of gerontologists, Aging Network representatives, and officials of 
national aging organizations was conducted in July. Based on the results of the 
review process, the Commissioner on Aging awarded 59 grants in August and Sep- 
tember. Grants for three of the priority areas — national aging organizations, nation- 
al non-aging organizations, and the National Eldercare Volunteer Corps were de- 
scribed earlier in this report. New projects awarded under the other priority areas 
as well as other Title IV projects which received continuation support in fiscal year 
1992 or remained active in 1992 are described below. 

a. Targeting Eldercare Support to Minorities 

The Older Americans Act specifies that special preference be given in its pro- 
grams to make services accessible to low-income and minority elderly. Although this 
preference is given consideration in making all discretionary grant awards, the Ad- 
ministration on Aging often sets aside support for project grants that seek to im- 
prove minority access to services as their primary goal. Five new project awards to 
target resources to the minority elderly were made to national minority organiza- 
tions in fiscal year 1992 under the Discretionary Funds Program Announcement 
and work continued on seven project awards funded in earlier years. The National 
Resource Center on Minority Populations also continued its work throughout the 
year. 

(1) Targeting Eldercare Resources 

The National Eldercare Campaign underscores the issue of the low-income minori- 
ty elderly' s need to access needed benefits and eldercare services. The following five 
national minority organizations were funded in fiscal year 1992 to develop outreach 
methods and strategies that target the at-risk elderly through their membership ac- 
tivities: 

The National Hispanic Council on Aging (Washington, DC) proposes to im- 
prove the Hispanic elderly's access to entitlement and aging services programs 
through the development and testing of a comprehensive set of outreach strate- 
gies in seven cities and through a national media campaign. 



Ill 



The National Pacific/ Asian Resource Center on Aging (Seattle, WA) proposes 
to empower its target population to gain access to the current service system by 
examining this service system and designing and distributing tools to enable 
majority/minority-based organizations and agencies to serve minority clientele 
more effectively. 

The National Caucus and Center on Black Aged (Washington, DC) will focus 
on improving the health status of African American elderly by increasing their 
access to information on health promotion and disease prevention and through 
a comprehensive set of outreach strategies. 

The National Indian Council on Aging, Inc. (Albuquerque, New Mexico) has 
been convening focus groups and meetings with national organizations to pre- 
pare an agenda for Indian elders. In addition, it has been encouraging proposals 
to increase the participation of Indian elders in SSI and other programs 
through an enrollment and outreach campaign to both rural and urban Indians. 

The Asociacion Nacional Por Personas Mayores (Los Angeles, CA) will carry 
out a project designed to improve the targeting of services to older Hispanics by 
increasing the numbers of Hispanic service providers that participate actively 
in the aging services network. 

(2) Minority Elderly Agendas 

Seven national aging and minority organizations, originally funded in Fiscal 
Years 1989 and 1990, completed their projects in Fiscal Year 1992. These projects 
developed or enhanced their knowledge of minority aging issues and broadened 
their capacity to deal with the concerns of low income minority elderly on an on- 
going basis. During fiscal year 1992, these organizations continued to be engaged in 
the following activities: 

The National Council of La Raza (Washington, D.C.) developed a national net- 
work of Hispanic and non-Hispanic community-based groups committed to serv- 
ing low-income Hispanic elderly; a number of guides to help Hispanic and non- 
Hispanic groups become involved in elderly services; and several resource 
guides. 

The National Caucus and Center on Black Aged (Washington, D.C.) in collabo- 
ration with the American Association of Retired Persons (Washington, D.C.) 
conducted activities in six cities to increase participation of the Black elderly in 
Older American Act programs and worked together to stimulate low income mi- 
nority elderly agendas in other national organizations. 

The Gerontological Society of America (Washington, D.C.) strengthened its 
commitment to minority concerns by increasing the number of sessions on mi- 
nority aging issues at its annual conference; creating a society-wide task force; 
giving presentations at national organizations on minority issues; conducting 
student and faculty research workshops; and placing minority post-doctoral fel- 
lows in community-based agencies serving minority elderly. 

The National Association of State Units on Aging (Washington, D.C.) promot- 
ed the use of State minority task forces by developing a technical assistance 
manual on minority aging; established eight pilot projects to develop activities 
focusing on minority elderly; and increased its internal organizational commit- 
ment to minority elderly concerns. 

The American Society on Aging (San Francisco, California) increased the visi- 
bility of minority elderly concerns by conducting eight leadership roundtables 
in various locations throughout the Nation, implementing a National Fellows/ 
Mentors Program, and conducting a minority membership campaign. 

The National Association of Area Agencies on Aging (Washington, D.C.) cre- 
ated a Minority Targeting Technical Assistance Center for its member agencies 
and developed and tested a self-assessment and training package to improve the 
responsiveness of Area Agencies on Aging to minority issues. 

The National Indian Council on Aging (Albuquerque, New Mexico) has been 
convening focus groups and meetings with national organizations to prepare an 
agenda for Indian elders. In addition, it has been encouraging the formation of 
Indian Councils on Aging in several States and a multistate region. 

(3) Resource Center on Minority Aging Populations 

The National Resource Center on Minority Aging Populations was established in 
Fiscal Year 1989 as a collaborative effort between San Diego State University in 
California, and the University of Southern California at Los Angeles. The Center 
has served as a national focal point for technical assistance, training, information 
dissemination, and short-term research. In Fiscal Year 1992, the Center continued 



112 



to provide the Aging Network with technical assistance via telephone, conferences, 
and written materials. Four quarterly newsletters were published in addition to 
"Resource Materials From Administration on Aging Discretionary Grants on Minor- 
ity Aging: An Indexed Descriptive Catalogue". This important document was dis- 
seminated through the Aging Network to assist in searching for available resource 
materials produced through AoA grants. A number of monographs from the June 
1990 symposium entitled "Diversity in an Aging America: Challenges for the 1990s," 
were disseminated to State Units on Aging and Regional Offices. The Center contin- 
ued to collaborate with a number of national aging organizations on conferences, 
publications and resource sharing. 

Through an extension to the project, the Center participated in sponsoring an 
"International Conference on Population Aging" in San Diego, California in Sep- 
tember 1992. The Conference highlighted aging among contrasting cultures and 
helped to deepen understanding about the cultural origins of minority elderly in 
this country. Conference recommendations will be shared with the United Nations 
for upcoming UN assemblies to consider. 

b. Supporting Resources for Eldercare Legal Assistance 

The new Title VII, established by reauthorization of the Older Americans Act on 
the last day of the Fiscal Year, mandates support for legal assistance programs 
funded through State and Area Agencies. This mandate was previously included 
under the Title III provisions which authorize grants to State and Area Agencies for 
nutrition and community support services. Section 424 of Title IV remains un- 
changed by the Amendments. It has required the Administration on Aging to estab- 
lish a national legal assistance support system that provides State and Area Agen- 
cies and local legal assistance programs with case consultations, training, legal 
advice, and assistance in the design and implementation of delivery systems by local 
providers. Under this mandate, the Administration on Aging has supported techni- 
cal assistance grants to national, nonprofit legal assistance organizations for a 
number of years through multi-year grant projects on the basis of periodic national 
competitions. In fiscal year 1992, eight new awards were made to fulfill this man- 
date, replacing the supportive services provided during much of the year by eight 
earlier grants. 

Continuation funding was also awarded in fiscal year 1991 to three demonstra- 
tions of state-wide legal hotlines initially supported in fiscal year 1992. Two other 
demonstration grants funded in fiscal year 1991 — one to resolve conflicts between 
Federal Indian policy and the policies of general entitlement programs and the 
other to develop and implement demonstration programs using State criminal histo- 
ry records as background checks on potential representative payees — were active 
throughout the year. 

(1) Grants to Build a National System of Legal Assistance Activities for the Elderly 

In Fiscal Year 1992, AoA made three-year project awards to eight national legal 
assistance organizations. These grants are designed to contribute toward building a 
national system of legal assistance activities in support of the National Eldercare 
Campaign, with special emphasis on enhancing the capability of State and Area 
Agencies on Aging and legal services providers to plan for and deliver legal assist- 
ance to those vulnerable elderly at risk of losing their independence. All projects 
will emphasize four activities to improve the quality and accessibility of legal serv- 
ices for older persons: (1) case consultations; (2) training; (3) the provision of substan- 
tive legal advice and assistance; and (4) assistance in the design, implementation, 
and administration of legal assistance delivery systems to local legal assistance pro- 
viders for older individuals. These projects are: 

The National Senior Citizens Law Center (Washington, DC). The Center will 
provide legal assistance support services to State and local legal assistance pro- 
grams for the elderly, legal assistance developers, ombudsmen, and State and 
Area Aging Agencies. Assistance will be provided through case consultation, 
legal assistance, technical assistance (TA), training, and joint sponsorship of the 
National Conference on Law and Aging. Products will be produced on such sub- 
jects as the new Americans With Disabilities Act. The products will include 
newsletters (NSCLS Washington Weekly); memoranda (Nursing Home Law 
Letter, Law and Aging Memorandum, Memorandum to Aging Advocates); Dis- 
ability Advocates Mailings and others related to age discrimination, in-home 
support, food stamps, home health, and housing; and other training materials 
(updates of COBRA Manual, and SSI Manual). The Center will continue to_ 



113 



assist legal assistance systems with Technical Assistance on standards and 
assist them in dealing with the impact of Title VII. 

The Commission on Legal Problems of the Elderly of the American Bar Asso- 
ciation (Washington, DC) will strengthen the capacity of State and Area Aging 
Agencies and legal services providers to develop accessible and responsive sys- 
tems of legal assistance for older persons. The Commission will provide techni- 
cal assistance on legal assistance systems related to subjects such as private bar 
involvement, senior attorney pro bono services, aging network linkages with dis- 
ability networks, offices of attorney generals, and eldercare coalitions. The 
major anticipated products and outcomes include: (1) co-sponsorship of the Joint 
Conference on Law and Aging, (2) a national symposium on ethical issues in 
elder law, (3) development and implementation of a training module on home 
equity conversion issues, (4) preparation of a briefing paper on home care liabil- 
ity issues, (5) publication of a provider guide to compliance with the Patient 
Self-Determination Act, (6) issuance of a quarterly newsletter, and (7) updates of 
existing publications including Effective Counseling of the Elderly, Where the 
Nation Stands, Law and Aging Resource Guide. 

The Mental Health Law Project of Washington, D.C. will provide training, 
technical assistance, and case consultation to advocates to meet the legal needs 
of elders with mental disabilities. It will emphasize protection of the rights of 
elders to age in place and promote community-based alternatives to nursing 
homes and appropriate care for the mentally disabled in nursing homes and 
hospitals, including options for community placements. 

The Pension Rights Center (Washington, DC) will expand its Legal Outreach 
Program, targeted to the needs of at-risk elderly and the legal services provid- 
ers that serve them. The Center will also develop new case consultation, train- 
ing and pro bono resources. The outcomes and products of its legal assistance 
activities will include an advanced pension law seminar, a pro bono pension 
clinic model, a private bar-sponsored case consultation panel, a lawyers network 
directory, three issues of a newsletter, and a self-help pamphlet in English and 
Spanish. The Center will also establish a Clearinghouse to collect and dissemi- 
nate pension information to eldercare providers. Clearinghouse outcomes and 
products include a "Pension Packet for Caregivers"; a survey and summary of 
examples of companies that have modified their pension plans to insure that 
employees who serve as family caregivers do not lose their pension credits due 
to absences from work; and a data base of information for pension fund manag- 
ers about "eldercare investment opportunities." 

The Legal Counsel for Elderly of the American Association of Retired Persons 
(Washington, DC) will provide training and technical assistance to past recipi- 
ents of "training the trainers" on substantive law and advocacy skills in 20 
States. The project will provide training to volunteers, staff of legal assistance 
and aging advocacy agencies, substantive experts who want to become trainers, 
and advocates in multidisciplinary coalitions who will, in turn, serve as train- 
ers. It will provide training and assistance to States interested in passing new 
rotective services legislation (guardianship, health care decision-making, dura- 
le powers of attorney, living will) and to States interested in expanding legal 
services programs for Disability, Medicare and Veterans benefits based on docu- 
ments maintained in its clearinghouse for these topics. It will continue previous 
activities to test, and, if successful, replicate methods for providing free legal 
assistance through (1) use of private practice paralegals as volunteers, (2) use of 
retired and semi-retired attorneys as volunteers, and (3) use of bar-sponsored 
lawyer referral programs to provide low cost wills and advance directives. 

The National Clearinghouse for Legal Services (Chicago, ID will provide a 
full range of publications and information services to agencies funded through 
AoA to provide legal assistance to older persons. Services include: computer-as- 
sisted legal research, Clearinghouse Review, Brief Bank services, and a comput- 
er newsletter. New services to be developed include the collection and organiza- 
tion of documents relating to elder law into a specialized electronic brief bank 
(instantly accessible through computers to AoA funded legal projects and serv- 
ices) and a searchable electronic index of the documents available in the elec- 
tronic brief bank. 

The Center for Social Gerontology (Ann Arbor, MI) will involve Title III legal 
providers and legal assistance developers in the National Eldercare Campaign 
by providing technical assistance (TA) to Eldercare Institutes, Project Care Coa- 
litions, State and Area Aging Agencies, legal providers, legal services develop- 
ers, ombudsman, and non-traditional groups such as the National Association of 
Women Lawyers. Outcomes will include a monograph and special working ses- 



114 



sions to educate members of the law and eldercare networks about the legal as- 
pects of eldercare issues. A newsletter, the 5th, 6th and 7th National Confer- 
ence on Law and Aging, and an update of the Comprehensive Guide and Eval- 
uation Manual, incorporating provisions of the Older Americans Act reauthor- 
ization, including the new Title VII on Elder Rights, will also be developed. 

The National Consumer Law Center, Inc. (Boston, MA) will provide legal sup- 
port to local practitioners (attorneys, legal services providers, legal service de- 
velopers and eldercare advocates) in applying consumer law to resolve legal 
problems facing elderly clients. It will develop a series of educational materials 
and guides, including model pleadings and defenses* model legislation, legal 
practice guides, newsletters and consumer education materials, with a special 
focus on threats to loss of shelter and financial exploitation. 
Eight 2-year legal assistance support grants, which began in fiscal year 1990, were 
active in fiscal year 1992. These projects and their area of expertise were: 

The Commission on Legal Problems of the Elderly of the American Bar Asso- 
ciation (Washington, D.C.) strengthened State legal assistance systems by link- 
ing and integrating them with other segments of the legal and judicial service 
systems and provided assistance and training in legislative tracking, model 
legal assistance standards, and private bar involvement. 

The National Senior Citizens Law Center (Washington, D.C.) provided techni- 
cal assistance, training and consultation to legal assistance providers funded 
under the Older American Act on Federal beneficiary programs and legal areas 
such as nursing home law, pension and retiree health care, protective services 
and age discrimination. 

The Mental Health Law Project (Washington, D.C.) provided training and 
technical assistance on legal matters relating to mental disabilities and protec- 
tion available to older persons confined in nursing homes and psychiatric hospi- 
tals including case and non-litigation consultation. 

The Pension Rights Center (Washington, D.C.) developed a National Lawyers 
Network which included lawyers in every State willing to assist older people 
receiving pensions; established pilot pension assistance projects in New York 
City, Philadelphia, Atlanta, Chicago, and San Francisco; and gave technical as- 
sistance to State legal assistance service systems and the private bar. 

The Legal Counsel for Elderly of the American Association of Retired Persons 
(Washington, D.C.) trained experts in various areas of legal assistance; supple- 
mented State systems of legal assistance with the support of Statewide volun- 
teer networks and local volunteer programs; sponsored training workshops on 
protective services; and provided technical assistance on the formation and op- 
eration of legal hotlines. 

The National Clearinghouse for Legal Services (Chicago, Illinois) provided a 
full range of legal information and research services to State Legal Services De- 
velopers and Title III funded legal service providers based on its computer-as- 
sisted legal research data base and published the Clearinghouse Review as a 
service to all Title III legal assistance providers. 

The Center for Social Gerontology (Ann Arbor, Michigan) provided in-depth 
support, often on-site, to individual States to strengthen their leadership capac- 
ity and service delivery system capability to provide accessible and efficient 
legal assistance. 

The National Bar Association (Washington, D.C.) worked with State Agencies 
on Aging to help them meet the legal assistance needs of low income, minority 
elderly through linkage and referral to members of minority bar associations, 
publications, and sponsorship of orientation and training programs. 

(2) Improvement of Access to Legal Assistance 

The current legal assistance network for older persons has been operational for a 
number of years and proved effective for persons who have used it. Experience has 
indicated, however, that barriers persist in reaching selective populations of older 
persons who are at-risk for a variety of reasons and could be aided if access were 
improved. 

(a) Statewide Legal Hotlines 

In fiscal year 1990, the Administration on Aging entered into a memorandum of 
understanding with the American Association of Retired Persons (AARP), Washing- 
ton, D.C, to expand the availability of Legal Hotlines for older people. The agree- 
ment followsup on earlier cooperative efforts which awarded seed money to develop 
hotlines in the District of Columbia, Florida, and Texas. Under the new agreement, 
AARP provided seed money for two additional hotlines (Ohio and Michigan) and 



115 



AoA for three new hotlines which it funded with two-year project grant support in 
fiscal year 1991. 

With the operation of legal hotlines in nine states (Pennsylvania served as the 
model for replication), nearly one-third of the nation's older people have free access 
to legal advice. When an older person with a legal problem calls the Hotline special- 
ly-trained lawyers either provide step-by-step advice on how to resolve their prob- 
lems immediately, or on more difficult issues, consult with local legal aid specialists 
or a panel of attorneys in private practice who agree to charge reduced fees. More 
than the three AoA projects awarded in fiscal year 1991 and which receive continu- 
ation funding in fiscal year 1992 are: 

The Maine hotline, operated by the Legal Services for the Elderly (Augusta, 
Maine) is serving as the primary intake mechanism for their Statewide network 
of legal assistance offices. 

The Arizona hotline, operated by Southern Arizona Legal Aid (Tucson, Arizo- 
na), is testing new strategies for outreach to the State's Native American and 
Hispanic populations. 

In New Mexico, the hotline is operated by the State Bar of New Mexico (Al- 
buquerque, New Mexico) which is expanding and improving their current pro 
bono program. 

(b) Entitlement Benefits for Tribal Elders 

In Fiscal year 1990, the Administration on Aging funded the Washington State 
Indian Council on Aging (Wapato, WA) to examine and resolve, through advocacy 
and casework, the problems faced by tribal elders in the application of Federal enti- 
tlement programs, primarily SSI, Medicaid, and VA Pension benefits. These entitle- 
ments are often found to be in conflict with health care, in-home health services, 
and Indian Trust income benefits, and other tribal benefit programs. The project 
has completed a survey and analyzed data from 11 tribes which document areas of 
concern. Products developed under the grant include a videotape of the congression- 
al hearings on Native American conditions, the survey, and a Legal Practice 
Manual on Indian Entitlements. 

(c) Representative Payees 

In 1991, the Administration on Aging entered into a cooperative agreement with 
the Social Security Administration (SSA) (Baltimore, MD) to jointly fund the Na- 
tional Criminal Justice Association (Washington, DC) to develop and implement ten 
demonstration programs for using State criminal history records to conduct crimi- 
nal history background checks on potential representative payees. Under the repre- 
sentative payee program, SSA appoints a person other than the beneficiary to re- 
ceive social security checks whenever it determines an entitled individual is incapa- 
ble of managing or directing the management of his or her monthly benefit pay- 
ment. The representative payee program is less costly and less intrusive in its over- 
sight of an individual's affairs than court appointment of a guardian. 

Under the terms of the agreement between AoA and the Social Security Adminis- 
tration (SSA), each agency alternates award of financial support to the grantee. Ini- 
tial funding awarded in fiscal year 1990 was provided by SSA. AoA provided second 
year support with continuation funding in early fiscal year 1992 with an active 
project period extended into mid-1993. Under the terms of its extension, The Nation- 
al Criminal Justice Association continues to work with the Social Security Adminis- 
tration and various State Agencies, primarily in the criminal justice area, to deter- 
mine if potential representative payees can be checked for criminal records before 
they are approved. SSA gave permission to include fingerprinting as part of crimi- 
nal background checks, with the exclusion of family members who are representa- 
tive payees. Demonstrations have been on-going or completed in various locations in 
Florida, New Jersey, Idaho, California and Missouri. 

c. Improving Preparation of Practitioners and Professionals 

The Administration on Aging is keenly aware of the continuing need to attract 
and adequately prepare qualified personnel for the field of aging. The quality of 
care provided through service programs in local communities, as well as profession- 
al services rendered by individuals in private practice and in institutions, is highly 
associated with the quality of education and training preparation. AoA has provided 
project support for improvements in specialized training for aging since its first year 
of operation and in recent years given emphasis to the development of training and 
placement programs for minority professionals and practitioners. 



116 



(1) Academic Training to Provide Better Eldercare Services 

In fiscal year 1992, AoA awarded nine new grants for education and training in 
response to a priority area for this purpose in the Discretionary Funds Program An- 
nouncement. These projects are: 

The Aging Studies program at the University of Iowa (Iowa City, IA) will 
work with the University of Northern Iowa and Iowa State University to con- 
duct a series of training activities on-campus and throughout the State. Activi- 
ties will include development of a rural peer counseling program, a weekly 
radio show, and a series of workshops for community volunteers and communi- 
ty coalition members. 

The Bureau of Geriatric Psychiatry at the Alabama Department of Mental 
Health and Mental Retardation (Montgomery, AL) will develop and implement 
a training program for public health nurses and social workers on recognition 
and management of dementia in rural communities. The Gerontology Center at 
the University of Alabama will assist in the development of educational materi- 
als which will be shared with staff of the Area Agency and Community Mental 
Health Center serving a six county area. 

The Center on Aging at San Diego State University (San Diego, CA) is con- 
ducting a series of activities involving collaboration between faculty, interns 
and community organization representatives on low-income, minority issues af- 
fecting service planning and effectiveness. Faculty from colleges and universi- 
ties in the San Diego region will serve as mentors to students who will work as 
interns in community agencies and use materials developed during the project 
to improve course work at their institutions. 

The Jacob D. Fuchsberg Law Center at Touro College (Huntington, NY) will 
use clinical interns and faculty advisors in development of an elderlaw specialty 
that offers pro-bono legal advice to low-income and minority elderly. The project 
has the cooperation and involvement of existing legal service programs and the 
local Area Agency on Aging. 

The Virginia Center on Aging at Virginia Commonwealth University (Rich- 
mond, VA) will be working with local chapters of the Alzheimer's Association, 
several State Agencies, and two minority enrollment academic institutions to 
develop and pilot test a program assisting Black and rural family caregivers of 
elderly with dementia. The Virginia Center on Aging is authorized by the State 
Legislature to serve as its policy research and development resource on aging 
issues. 

The University of San Jose (San Jose, CA) is developing a program in which 
upperclass students can fulfill their required community service credits with 
aging agencies and organizations. The University is one of the few institutions 
in the United States that makes community service a requirement for gradua- 
tion in a number of their undergraduate programs. 

The University of Kansas (Manhattan, KS) will increase the supply and qual- 
ity of community-based workers that serve the Indian elderly and increase 
public awareness, organizational outreach and coalition building through the 
mobilization of resources at six American Indian Colleges on behalf of at-risk 
Indian elders. The project will replicate a proven home care worker curriculum 
at each college, train students and evaluate each program. 

Shaw Divinity School (Raleigh, NC) will continue to develop a continuing cer- 
tificate program in eldercare ministries at Shaw Divinity School. At the end of 
the grant the faculty will have the expertise to conduct the academic program 
modeled and tested under this grant. 

Tougaloo College (Tougaloo, MS) will contribute to the development of strate- 
gies and systems addressing the needs of "at-risk" elderly, through training of 
students and faculty, increasing public awareness of the National Eldercare 
Campaign, and identifying resource gaps that must be considered as Mississippi 
formulates its "aging agenda." 

(2) Minority Management Training Program 

In fiscal year 1992 AoA funded eight special training projects in support of the 
National Eldercare Campaign under its continuing Minority Management Training 
Program to increase the number of qualified minorities in key management/admin- 
istrative positions in State and Area Agencies and other agencies. The goal is to in- 
crease the professional credentials of minority trainees to help those individuals 
make the transition from a staff level to a managerial and administrative position. 
Projects awarded were: 



117 



The Asociacion Nacional Por Personas Mayores (Los Angeles, California) to 
select, train, and place six (6) Hispanic graduates/ professionals in six-month 
managerial traineeships in public and private aging-related agencies. 

National Caucus and Center on Black Aged (Washington, DC) to secure the 
cooperation of four long term care facilities to train four African Americans in 
all phases of nursing home operation; prepare the trainees to pass State nursing 
home administrators licensure examinations; obtain permanent placement posi- 
tions for the participants; and expand the network of minority administrators 
nationwide. 

The National Hispanic Council (Washington, DC) to increase the pool of His- 
panic administrators/ managers with the skills and capacity to work in the 
aging network. Trainees will be placed in a range of host agencies, including. 
State and Area Agencies on Aging and public and private aging service agen- 
cies. 

Detroit Area Agency on Aging (Detroit, Michigan) to provide management 
training and employment for Hispanics to serve the Hispanic elderly who are 
20% of Detroit's elderly. 

National Council of La Raza (Washington, DC) to recruit, train and place His- 
panics in managing and administrative positions of community-based aging 
service organizations. 

Hunter College, CUNY (New York, NY) to enhance minorities' professional 
career mobility in aging through aging, management and minority specialized 
social work education. 

National Hispanic Council on Aging (Washington, DC) to increase the number 
of Hispanics with skills to function at the management level in Aging Network 
organizations. 

National Association of Area Agencies on Aging (Washington, DC) to train 
and place minorities in leadership positions within the Aging Network, especial- 
ly Area Agencies on Aging. 
In fiscal year 1991 AoA funded five projects operational in 1992 which carried out 
the following activities: 

Florida Agricultural and Mechanical University (Tallahassee, FL) has been 
engaged in recruiting, training, and placing minority interns in aging network 
agencies throughout the State of Florida. 

The Asociacion Nacional Por Personas Mayores (Los Angeles, CA) has been 
successful in recruiting, training, and placing nationwide, Hispanic graduates in 
public and private aging-related agencies. 

The National Caucus and Center on Black Aged, Inc. (Washington, DC) has 
focused its efforts on black health care management graduates, placing them in 
long term care facilities to enable them to complete State required management 
training programs and to pass State licensure examinations. 

Boston College (Boston, MA) has recruited minority persons for graduate 
training in social work and in the management planning of elder services fol- 
lowed by field placement in management positions in eldercare agencies and 
other parts of the aging network. 

The Association for Gerontology and Human Development in Historically 
Black Colleges and Universities (Washington, DC) has developed a model Minor- 
ity Management Training Program in rural Eldercare service delivery. 

(3) Promoting Eldercare Concepts in Academic Institutions 

In September 1991, eight awards were made under the Discretionary Funds Pro- 
gram Announcement to encourage faculty in academic institutions to incorporate 
concepts of the National Eldercare Campaign in their instructional programs. The 
grants were also designed to encourage faculty to work cooperatively with communi- 
ty planning and service organizations to develop student placements in roles that 
would give them experience with the concerns and needs of vulnerable older per- 
sons. Grants which were active throughout 1992 are: 

The University of North Texas (Denton, TX) established linkages between fac- 
ulty/student teams in colleges and universities, Area Agencies on Aging, and 
service provider contract agencies to build a cadre of academic faculty involved 
in eldercare coalitions. 

Shaw Divinity School (Raleigh, NC) initiated a continuing certificate program 
in eldercare ministries which will require students to participate in an off- 
campus assessment of the needs of 65+ Black elders in two rural counties. 

Portland State University (Portland, OR) trained faculty in coalition building, 
and involved them in development of eldercare coalitions. 



118 



Hunter College of the City University of New York (New York, NY) linked 
the community college system with service agencies on behalf of the Eldercare 
Campaign. 

Tougaloo College (Tougaloo, MS) conducted research, training and informa- 
tion dissemination to improve the full spectrum of eldercare training and serv- 
ices in the State. 

Baylor College of Medicine (Houston, TX) performed in-service faculty devel- 
opment in eldercare for key field placement site coordinators and added aging 
content to courses taken by 1,000 students. 

Marygrove College (Detroit, MI) expanded its gerontology curriculum and in- 
volved students and faculty in the operations of its on-campus senior housing 
complex. 

The State University of New York Health Sciences Center (Syracuse, NY) 
trained faculty from institutions throughout up-state New York in topics re- 
garding the at-risk elderly and methods for coalition building, then paired them 
with local aging service planners and providers to involve campus resources in 
Eldercare coalitions. 

(4) Dissertations 

In Fiscal Year 1991 AoA made four grant awards to support doctoral disserta- 
tions, and project activities are still on-going. The dissertations focus on the elder- 
care needs of at-risk older persons and the care provided such persons through 
home and community-based services. Awards were made to specific doctoral candi- 
dates at the following institutions: 

The University of Minnesota in Minneapolis for a study of "Innovative Long- 
Term Care Programs For The Elderly;" 

The University of California at San Francisco for a survey and review of 
"Adult Day Care Funding Strategies;" 

Brandeis University (Waltham, MA) for a study of the "Massachusetts Adult 
Foster Care Program;" and 

The University of Denver (Colorado Seminary) for an exploration of "Self-Ne- 
glect Among Elders In the Community." 

(5) Recruitment, Training, and Retention of Homecare Workers 

To help meet the need to increase and improve the supply of paraprofessional 
home care workers, AoA, in Fiscal Year 1991, funded four projects to test new, col- 
laborative approaches for recruiting, training, and retaining in-home workers. These 
projects, which continued in operation in fiscal year 1992, are: 

The University of Kansas in Lawrence — to design and implement a model 
home care worker training program appropriate for American Indian settings; 

The Denver Department of Social Services (Denver, CO) — to demonstrate a 
program which provides job training skills and cash and supportive service in- 
centives to prepare and hire Aid to Families with Dependent Care clients as 
home care workers; 

The Marin County Area Agency on Aging (San Rafael, CA) — to develop a 
model home care training and placement demonstration; and 

The Council for Jewish Elderly (Chicago, IL) — to develop training programs 
for: independent home care workers, family caregivers, and home care providers 
and to create a State coalition to improve conditions for home care workers. 

d. Linking Older Volunteers With Community and In-Home Service Programs 

The use of older volunteers in Older Americans Act programs at the State and 
local level has been a vital part of the success in reaching and giving assistance to 
millions of older persons through community and in-home service programs. Recog- 
nition of their service and encouragement to increase their commitment to volun- 
teer service is a major component of the National Eldercare Volunteer Corps pro- 
gram, part of the National Eldercare Campaign. The Administration on Aging rec- 
ognizes, however, that the volunteer interests of older Americans extend far beyond 
the service programs supported by the Older Americans Act. In recent years, AoA 
has supported a series of project grant clusters to demonstrate the effectiveness of 
older volunteers in other service programs, always keeping in mind that truly effec- 
tive programs reward and bring satisfaction to those who volunteer their time and 
effort. Four of these project clusters are described below. 



119 



(1) Eldercare Volunteer Service Credit Demonstrations 

Fiscal Year 1992 project awards were made to test new models and replicate exist- 
ing models of the volunteer service credit concept. The basic service credit concept is 
to give volunteers a credit unit for each service hour performed, regardless of the 
type of service, in the expectation that accrued credits will be redeemed in services 
by the volunteer at some future time of need. 
The Five model volunteer service credit projects funded were: 

Alliance For Aging (Miami, FL) is an Area Agency on Aging in South Florida 
which is proposing to expand the service credit concept through community- 
based organizations including: an interfaith council of churches and synagogues 
serving their congregants; The Dade County Housing and Urban Development 
Senior Housing Authority which will serve the elderly in public housing; the 
Dade County Public Schools which will establish day care centers manned by 
Senior Aides; and the South Florida AFL-CIO which will recruit service credit 
volunteers from its membership. 

The University of Pittsburgh (Pittsburgh, PA) will expand services to home- 
bound elderly through a intergenerational approach. Older persons and young 
^adults will provide services to homebound elderly and earn volunteer service 
credits. Young mother/older mother teams will contribute credits in return for 
— —child care. The project will target an African American community in Pitts- 
burgh. 

Sutter Hospital Foundation (Sacramento, CA) will adapt its' experience in 
providing a volunteer service credit program for middle class older persons to 
the needs of a low-income, minority community in Sacramento, California. 

Delaware Division on Aging (New Castle, DE), which is responsible for serv- 
ing a single state-wide planning and service area, is working with a church re- 
lated service provider to develop and test a volunteer service credit program op- 
erating through black churches to reach the minority elderly population in Wil- 
mington, Delaware. 

Our Lady of Lourdes Associates Foundation (Camden, NJ) is testing the serv- 
ice credit concept in the business/industry setting by assisting employers in set- 
ting up service credit banking programs for employees with caregiver responsi- 
bilities in a large company. During year two the project will expand to at least 
three additional business sites. 
In addition to the five projects, an award was made to provide technical assist- 
ance, training, and capacity-building services to the demonstration projects: 

The Time Dollar Network (Washington, DC) will accelerate the start-up and 
implementation of the approved demonstrations through the provision of clus- 
ter meetings, teleconferences, and site visits; promote the concept of volunteer 
service credit programs throughout the country by working with other organiza- 
tions interested in the concept and by giving presentations at national confer- 
ences; and promote replication of the basic model in other communities. 

(2) Volunteer Senior Aides 

In Fiscal Year 1991, AoA implemented Section 10404 of the 1989 Omnibus Budget 
Reconciliation Act which authorized a community-based, intergenerational, demon- 
stration program. The purpose of the program is to determine to what extent basic 
medical assistance and support, provided by volunteer senior aides, can reduce the 
costs of care for disabled or chronically ill children. The prototype program upon 
which the authorizing provisions were based is "Family Friends," an intergenera- 
tional program established in 1986 by the National Council on the Aging (NCOA), 
with funding support provided by the Robert Wood Johnson Foundation. 

To implement the Volunteer Senior Aides Program, AoA awarded demonstration 
grants to six Area Agencies on Aging to collaborate, over a three-year period, with 
local organizations in their respective communities to: (1) determine the impact of 
the older volunteers' services on the costs of care for disabled/chronically ill chil- 
dren; (2) promote the self-sufficiency of individuals and families vulnerable to a loss 
of independence; and (3) increase the volunteer senior aides' feelings of self-worth. 
Increased collaboration is expected among private, voluntary, and public sector or- 
ganizations in establishing and operating programs from which children, families, 
and older persons gain mutual support and benefits. 

In Fiscal Year 1992, AoA awarded continuation grants to all six projects to contin- 
ue these demonstrations for a second year. AoA is also providing support to NCOA 
to provide technical assistance, based upon their "Family Friends" expertise, to the 
Volunteer Senior Aides grantees in implementing these demonstrations. In addition, 
a summary evaluation of outcomes has been designed and is being conducted by one 



120 



of the grantees, the Mid-America Regional Council Commission on Aging (Kansas 
City, Missouri). The following projects, demonstrating the value of Volunteer Senior 
Aides, are in progress: 

The Los Angeles County Area Agency on Aging (Los Angeles, CA) is collabo- 
rating with Jewish Family Services of Los Angeles and Huntington Memorial 
Hospital of Pasadena so that senior volunteer aides can provide assistance to 
the families of low-income and minority children who are ill or disabled. Includ- 
ed are families in which grandparents are raising disabled or ill grandchildren 
who have been adversely affected by their mothers' drug abuse and/ or have Ac- 
quired Immune Deficiency Syndrome (AIDS). 

The CrossRoads of Iowa Area Agency on Aging (Des Moines, IA), in collabora- 
tion with the Easter Seal Society of Iowa, has and is recruiting and training 
senior volunteers from a primarily rural area to serve disabled or ill children. 
Through prevention, the project is expected to reduce the risk of placement out- 
side the home which can result when families have neither supportive services 
nor anyone to turn to. This voluntary assistance is expected to result in a 25 
percent decrease in the cost of care. 

The Mid-America Regional Council Area Agency on Aging (Kansas City, MO) 
is collaborating with the Children's Mercy Hospital in Kansas City and the Uni- 
versity of Missouri's University Affiliated Program for Developmental Disabil- 
ities to significantly expand upon an existing Family Friends Program. This 
project is assisting families in an inner-city area and developing replicable 
models to benefit special needs populations. Trained volunteers are currently 
assisting foster/adoptive families of infants who are medically fragile (including 
those exposed to cocaine before birth). 

The Region IV Area Agency on Aging (St. Joseph, MI), in collaboration with 
the local Foster Grandparents Program, is placing volunteer senior aides with 
families of children who have special physical or emotional needs. For each 
placement, it is expected that the volunteer will become a standard component 
of the family's treatment plan. 

The Philadelphia Corporation for Aging (Philadelphia, PA), in cooperation 
with Temple University's Center for Intergeneration Learning and the Institute 
on Disabilities, is recruiting, training, and supervising volunteer aides to pro- 
vide in-home support to disabled children and their families. Through this pro- 
gram, the health and social service delivery systems will gain a pool cadre of 
carefully trained older volunteers who can provide needed support to children 
with special needs and their families. 

The County of Riverside Office on Aging (Riverside, CA) is currently linking 
older volunteers with at-risk families of disabled/ chronically ill children to in- 
crease the availability of respite care and domestic management training for 
caregiving families. 

(3) Senior Home Companion AoA/ ACTION Projects 

In 1990, AoA and ACTION jointly initiated a three-year demonstration program 
to expand the number of Senior Companion volunteers providing in-home services 
to the frail, homebound elderly with award of 11 grants. These grants received con- 
tinuation support from both agencies in fiscal year 1992. 

AoA in conjunction with ACTION sponsored a major training conference of the 
project directors in June, 1992 for information sharing, networking and skill devel- 
opment in gaining private sector support for the senior companions. ACTION and 
AoA have cooperatively undertaken an evaluation of the program's effectiveness 
and applicability nationwide. Outcomes achieved to date include the addition of a 
minimum of five additional senior volunteers in each demonstration and in one or 
more projects, new Alzheimer's respite care services, new services in low-income 
senior housing, new services to Native Americans, and establishment of new volun- 
teer stations and services in new geographical areas. The on-going projects are ad- 
ministered by the following State Agencies on Aging: 

The Vermont Department of Aging and Disabilities (Waterbury, VT) 
The Pennsylvania Department of Aging (Harrisburg, PA) 
The Virginia Department of the Aging (Richmond, VA) 

The Florida Department of Health and Rehabilitative Services (Tallahassee, 
FL) 

The Georgia Department of Human Resources (Atlanta, GA) 
The Kentucky Department for Social Services (Frankfort, KY) 
The Wisconsin Bureau of Aging (Madison, WI) 
The Minnesota Board on Aging (St. Paul, MN) 



121 

The New Mexico State Agency on Aging (Santa Fe, NM) 

The Missouri Department of Social Services (Jefferson City, MO) 

The Nevada Department of Human Resources (Las Vegas, NV) 

(4) Use of Older Volunteers in Head Start Programs 

The Administration on Aging and the Head Start Program of the Administration 
for Children and Families jointly funded two-year project demonstrations of the use 
of older volunteers in Head Start Agencies. In most projects, Head Start Program 
grantees were paired with local aging organizations and agencies which use older 
volunteers in their own activities to assist in recruitment, training, and placement 
for eventual placement in such Head Start Program roles as family mentors, class- 
room aides, and program management assistants. 

Projects received funding for their last year in late fiscal year 1991 and were oper- 
ational throughout fiscal year 1992. Documentation of procedures, practices and ma- 
terials used for recruitment, orientation and training of volunteers were being pre- 
pared for submission with final reports due late in the year. A synthesis report of 
the accomplishments of these projects will be prepared by the Head Start Program 
for distribution in calendar year 1993. Head Start Program agencies and their col- 
laborating aging organizations were: 

Hawkeye Area Community Action Program (Cedar Rapids, IA), Heritage 
Agency on Aging, and Retired Senior Volunteer Program of Lynn County; 

Chautauqua Opportunities, Inc. (Mayville, NY), Chautauqua County Office for 
Aging, and Retired Senior Volunteer Program; 

Coastal Community Action Program (Aberdeen, WA), and Grays Harbor Re- 
tired Senior Volunteer Program; 

Bi-County Community Action Council, Inc. (Bemidji, MN) and Beltrami and 
Cass County Senior Citizen Councils on Aging; 

Community Action Inc. of Hayes, Caldwell and Blanco Counties (San Marcos, 
TX) and American Association of Retired Persons (San Marcos, Blanco, and 
Lockhart Chapters); 

Cen-Clear Child Services, Inc. (Philipsburg, PA) and Clearfield County Area 
Agency on Aging; 

Central Nebraska Community Services, Inc, (Loup City, NE) and South Cen- 
tral and Northeast Nebraska Area Agencies on Aging; 

Community Action Agency of Somerville, Inc. (Somerville, MA) and Somer- 
ville Council on Aging; 

Mahube Community Council, Inc. (Detroit Lakes, MN) and Retired Senior 
Volunteer Program; and 

Board of County Commissioners Hillsborough Head Start Department 
(Tampa, FL). 

e. Reaching the Most Vulnerable 

The primary goal of the National Eldercare Campaign and the major mandate of 
the Older Americans Act is to develop and improve access to community and in- 
home services for the most vulnerable elderly in our society — individuals who with- 
out the support of family caregivers and supportive service programs are in danger 
of losing their independence and are at-risk of institutionalization. Three of these 
vulnerable sub-populations, persons victimized by abuse, individuals afflicted with 
Alzheimer's Disease and related disorders, and families headed by older adults 
caring for children with disabilities, have been the focal point of recent Administra- 
tion on Aging demonstrations. 

(1) Elder Abuse Initiative and Activities 

The Administration on Aging (AoA) is the lead agency of Department of Health 
and Human Services Elder Abuse Task Force as established by Secretary Louis Sul- 
livan. The Elder Abuse Task Force consists of the top leadership of AoA, the Office 
of the Assistant Secretary for Planning and Evaluation, the Health Care Financing 
Administration, the Public Health Service, and the Social Security Administration. 
In July 1991, the Secretary approved the Task Force's recommended elder abuse 
strategy which addresses elder abuse in both institutional and residential (home) 
settings. The elder abuse strategy is made up of three components: 

The production of research data that will contribute to better understanding 
of the nature and scope of the problem; 

The promotion of training and technical assistance activities that enable 
states and localities to respond to these problems; and 



122 



A focus on public education activities to better inform both professionals and 
voluntary groups who are responsible for and concerned about how to combat 
elder abuse. 

AoA has made available the resources of the National Eldercare Institute for 
Elder Abuse and State Long Term Care ^Ombudsman Services to assist the Task 
Force in carrying out the training and technical assistance component. By spring 
1993, an assessment will be completed of what elder abuse 7 network agencies need in 
the form of information, training, and capacity building. AoA will then consider 
strategies, including activities, to respond to identified priority needs. Such activi- 
ties may include workshops and seminars, grant announcement priority areas, in- 
formation packets, training and technical assistance materials. The Institute will 
assist in carrying out the training and technical assistance plan of action when ap- 
proved by AoA for implementation in Fiscal Year 1994. 

To move forward to implement the public education component, AoA has dis- 
cussed with the National Eldercare Institute on Elder Abuse and State Long Term 
Care Ombudsman Services collaborative activities to complement the Secretary's 
Elder Abuse Task Force's priorities in this area. The following actions are under 
consideration: a national event to announce an elder abuse public education cam- 
paign; regional follow-up meetings; and dissemination of best practices in State/ 
local elder abuse systems to enhance service systems coupled with increased public 
and professional awareness resulting from public education activities. In addition, 
AoA plans to devote the complete winter issue of Aging to elder abuse issues. 

(2) Improving Services to Older Persons With Developmental Disabilities 

As increasing numbers of older persons with developmental disabilities are aging 
while living at home with their families, the capacity of their elderly parents to con- 
tinue as caregivers is at risk. Effective coordination and delivery of supportive serv- 
ices to these individuals is crucial. To help address these needs, in fiscal year 1990, 
AoA awarded four (4) grants for projects to be carried out jointly by State Agencies 
on Aging and State Developmental Disabilities Planning Councils to develop aging/ 
Developmental Disabilities State and local planning linkages. These projects contin- 
ued through fiscal years 1991 and 1992. The Administration on Developmental Dis- 
abilities (ADD) co-funded three (3) of these projects. These collaborative models dem- 
onstrated — and fostered the replication of — improved delivery of services to older 
persons with DD and their aging family caregivers: 

The New York State DD Planning Council (Albany, NY), in collaboration 
with the New York State Office of Mental Retardation and DD and the State 
Office for the Aging, produced and disseminated technical "how-to" manuals 
based on cross-network integration and assisted other States with implementa- 
tion. Technical assistance was given via: national, formal, workshops; ad hoc 
workshops; and a national telephone line. The project provided national leader- 
ship, ultimately helping to integrate older persons with DD into aging programs 
in communities across the country. 

The Missouri Department of Social Services' Division of Aging (Jefferson City, 
MO), in cooperation with the Missouri Planning Council for DD and the Univer- 
sity of Missouri's Interdisciplinary Training Center on Gerontology and Devel- 
opmental Disabilities, established: a centralized resource center for older per- 
sons with DD, their caregivers, and professionals; a caregivers' network and 
protective services hotline; and an ongoing mechanism for Statewide planning 
and collaboration. 

The Wisconsin Council on DD (Madison, WI) and the Wisconsin Bureau on 
Aging, in cooperation with the Center on Mental Retardation and Human De- 
velopment at the University of Wisconsin, promoted life-long planning and es- 
tablished new linkages between the aging and DD service sectors (both formal 
and informal) to improve opportunities for older persons with DD. This project 
focused on case-finding, identifying the unserved, particularly in rural areas, 
and targeted older American Indians with developmental disabilities. Issue 
papers on needs for legislative change and expansion of services were devel- 
oped; findings will be incorporated into a legislative package for the next bien- 
nial State budget. 

The Virginia Department for the Aging (Richmond, VA), the Board for the 
Rights of Virginians with Disabilities, and the Virginia Center on Aging and 
the Virginia Institute on DD at Virginia Commonwealth University, worked in 
partnership to enhance the community-based, long-term care system for older 
persons with developmental disabilities and their aging parents. This partner- 
ship resulted in: recommendations to reduce regulatory, programmatic, budget- 



123 



ary, and personnel barriers to services; a core of 243 cross-trained personnel; a 
National directory on aging and developmental disabilities; and tested local 
strategies to identify and assist older adults with developmental disabilities. 

(3) Supporting Alzheimer's Disease Victims and Their Family Caregivers 

The recent Amendments to the Older Americans Act give the Administration an 
additional mandate to focus attention on the unmet needs for home and community 
based services of at-risk older people and their caregivers. The most recently sup- 
ported activity, support of the new National Eldercare Institute on Long Term Care 
and Alzheimer's Disease at the University of South Florida and a grant to the Alz- 
heimer's Association, both awarded in fiscal year 1992, are described in an earlier 
portion of the Title IV section of this report. 

AoA previously awarded three projects grants in fiscal year 1990 which were de- 
signed to help improve access to services by minority persons with Alzheimer's Dis- 
ease and their family caregivers. These projects were still active earlier in fiscal 
year 1992. Each project focused on a different minority group of older people and 
demonstrated innovative and effective ways to meet such persons special informa- 
tion needs. These projects and their achievements are: 

Morehouse School of Medicine, Department of Community Health and Pre- 
ventive Medicine (Atlanta, GA) designed and implemented a model community- 
based information and service program for Blacks with Alzheimer's Disease and 
their family caregivers. 

Institute for Community Research (Hartford, CT) developed and disseminated 
educational materials on Alzheimer's Disease for Puerto Rican elderly, their 
caregivers, and social and health service providers. 

Hawaii Executive Office on Aging (Honolulu, HI) developed, tested and evalu- 
ated a multilingual, multimedia outreach campaign on information and support 
services for Alzheimer's patients and families of Japanese, Korean, Chinese, Fil- 
ipino, Hawaiian, Samoan and Southeast Asian ethnicity. 

f. Improving Supportive Service System Visibility and Coordination 

Another major theme of Title IV projects in recent years has been support of 
demonstrations and developmental efforts which improve coordination among sup- 
portive services supported by Older Americans Act program agencies and other sys- 
tems. Three recent efforts with this common goal have been in areas of housing, 
long term care, and use of a national 800 number for long distance caregiving. 

(1) Information and Referral Services 

Information and referral (I&R) service which link persons in need with appropri- 
ate service to meet or alleviate that need has been a priority of Older Americans 
Act programs since 1973 when the reauthorization amendments required State and 
Area Agencies on Aging to establish them within convenient access to all older per- 
sons. Since the mandate was given, AoA has worked with a number of organizations 
to establish policies and develop technical assistance handbooks promoting I&R 
services. Although much has been accomplished, the dramatic increases in the older 
population and introduction of new technologies, AoA recognized that improvements 
in such areas as training, technical assistance, and standards of operation (last re- 
vised in 1983), were required. 

a. Eldercare Locator 

In fiscal year 1990, a three-year grant was awarded to the National Association 
for Area Agencies on Aging (Washington, D.C.) to establish a national locator serv- 
ice. The Eldercare Locator features a national 800 number through which callers 
can locate the name, address, and the information and referral telephone number 
for an Area Agency on Aging anywhere in the country. A major effort of the project 
is to develop financial support for the locator system from the private sector espe- 
cially corporate sponsorship. Anticipated results of this locator system include: 

— greater recognition of the need for and existence of eldercare and the at-risk 
elderly; 

— greater national recognition of existing community I&R systems through a na- 
tional toll-free telephone number providing callers with referrals to local Area 
Agencies on Aging and /or their I&R providers; 

— a consistent and uniform identity for the Aging Network as a result of a public 
information campaign announcing the locator service; and 



65-505 - 93 - 5 



124 



— reduction of the difficulties faced by long-distance caregivers in linking their 
older parent or relative with appropriate supportive services. 

The locator system was implemented nation-wide effective November 1992. Over 
12,200 calls were handled by the locator system since it was first implemented in 
May 1991 and October 1992. Now that the system is nationwide, it is expected that 
the call volume will increase substantially. The National Association of Area Agen- 
cies on Aging launched a major publicity campaign for the locator during the week 
of Thanksgiving, 1992 in conjunction with National Family Caregivers Week. This 
should also increase the volume of calls for the locator. 

National Information and Referral Center 

In fiscal year 1990, a three year project grant was awarded to the National Asso- 
ciation of State Units on Aging (Washington, D.C.) who will work with the National 
Association of Area Agencies on Aging (Washington, D.C.) and the Alliance of Infor- 
mation and Referral Systems (Bethesda, Maryland) to establish a National Informa- 
tion and Referral Center to enhance the capacity of State aging Information and 
Referral systems. 

The Center will assist I&R providers to participate in Eldercare Coalition by con- 
tributing their knowledge of aging needs and establish standards for Information 
and Referral systems which help older people. The Center will promote I&R systems 
improvement as a priority with the Aging Network, in part by establishing a na- 
tional information exchange to provide access to existing I&R training materials, ex- 
perts and best practices and providing training and technical assistance. It will also 
help individual States and Area Agencies on Aging facilitate the development of 
I&R systems improvement plans; 

During fiscal year 1992, the I&R Center disseminated over 3000 quarterly issues 
of its newsletter, the "I&R Reporter," throughout the aging network to States and 
Area Agencies on Aging, Title III funded I&R providers and other aging and I&R 
professionals. Six I&R Mini Grants were awarded to assist States to implement 
their I&R systems improvement plans, test innovative approaches to improve I&R 
provision and replicate good I&R models. Standards for Older Americans I&R Pro- 
grams were completed and sent to the aging network as well as and OAA Standards 
Implementation Guide which will offer incremental steps for compliance with the 
standards. A training curriculum to assist States to implement these standards as 
well as model I&R programs was developed and tested. The I&R Center also assisted 
the National Association of Area Agencies on Aging in planning and training ses- 
sions for Regional and State I&R personnel to assist them in implementing the El- 
dercare Locator. 

(2) Housing and Supportive Services 

Five (5) State Housing Finance Agencies and four (4) State Agencies on Aging 
(funded in fiscal year 1990 and 1991) continued to design or to expand the availabil- 
ity of supportive services to moderate and low income frail elderly in federally-sup- 
ported facilities. These projects have been quite successful and have developed a 
number of products, including training manuals, videos, functional assessment tools 
and survey instruments, directories of services and pilot projects. In November 1991, 
AoA conducted a two day workshop bringing the nine grantees together with repre- 
sentatives of national housing organizations. In August 1992, AoA, with the assist- 
ance of the National Eldercare Institute on Housing and Supportive Services, spon- 
sored a cluster meeting with the grantees. Both sessions enabled the grantees to fur- 
ther share their experiences with each other and to discuss strategies for product 
dissemination at the end of the grants. Project staff have also shared their successes 
at several national conferences. Many of these projects will become institutionalized 
at the end of the grant period. The projects are: 

The New York State Office for the Aging (Albany, NY) has facilitated access 
to community services for residents of up to fifteen (15) community State-assist- 
ed rental housing programs. 

The Colorado Housing and Finance Authority (Denver, CO) coordinated an 
array of support services to sight impaired, low-income and minority elderly 
residents in State financed Section 8 housing throughout the State. 

The Connecticut Housing Finance Authority (Rocky Hill, CT) assisted private 
management companies who hire social service staff to work directly with el- 
derly residents in six housing developments. 

The Ohio Department of Aging (Columbus, OH) developed a model supportive 
services program for demonstration at two (2) sites with Statewide training for 



125 



housing managers on use of an assessment screening tool to determine the serv- 
ice needs of frail elderly residents. 

The Vermont Housing Finance Agency (Burlington, VT) established a five 
region, State-wide, supportive service system for elderly in subsidized housing, 
including seniors living in over 84 State subsidized housing developments. 

The New Hampshire Housing Finance Authority (Bedford, NH) collaborated 
with the State Department of Human Services to develop a referral, advocacy 
and training program for housing managers and supporting three pilot projects 
addressing supportive service needs. 

The Minnesota Board on Aging (St. Paul, MN) developed training materials 
and offering financial incentives to communities to hire senior housing on-site 
coordinators who will help elderly tenants arrange for supportive services. 

The New Jersey Housing and Mortgage Finance Agency (Trenton, NJ) devel- 
oped a referral network and services resources directory with education of hous- 
ing managers, families and tenants on the need for and availability of support- 
ive services. 

The Arkansas Department of Human Services (Little Rock, AK) formed a 
state-wide commission of housing and aging professionals to promote support 
service resources and the training of housing unit managers to be more respon- 
sive to the needs of elderly residents. 

(3) State Long Term Care Projects 

In fiscal year 1990 nine grants were awarded to assist State Agencies on Aging 
develop collaborative efforts with other State Agencies, Area Agencies on Aging, 
and others to plan and implement specific improvements in State long term care 
systems. These grants, still active in fiscal year 1992, were made to the following 
State agencies: 

The Older Alaskans Commission (Juneau, AK) coordinated interagency ef- 
forts to include those elderly not eligible for medicaid as well as those eligible 
for medicaid in the states system of long term care. 

The Arizona Department of Economic Security/ Aging and Adult Administra- 
tion (Phoenix, AZ) demonstrated approaches to linking Older Americans Act 
and Medicaid systems in 13 rural counties. 

The Colorado Department of Social Services /Medical Services (Denver, CO) 
linked State aging, social service, Medicaid and vocational rehabilitation agen- 
cies to address Statewide case management practices. 

The Florida Department of Health and Rehabilitation Services/ Aging and 
Adult Services (Tallahassee, FL) demonstrated the extent to which enhanced 
hospital-based pre-admission screening and improved aging network and institu- 
tional linkages may affect community placements of older persons. 

The Hawaii Office on Aging (Honolulu, HI) in conjunction with key State 
agencies, Area Agencies on Aging, and other segments of the aging network, 
developed a comprehensive long term care plan required by the State legisla- 
ture. 

The Missouri Department of Social Services/Division on Aging (Jefferson 
City, MO) implemented a comprehensive long term care planning process in co- 
operation with Area Agencies on Aging and other State agencies. 

The Ohio Department on Aging (Columbus, OH) developed an interagency 
plan for home and community-based care to provide a policy framework for 
recent "Eldercare" initiative approved by the State legislature. 

The West Virginia Commission on Aging (Charleston, WV) planned and car- 
ried out several State long term care system improvements in cooperation with 
other State agencies and Area Agencies on Aging. 

The Wisconsin Department of Health and Social Services/Bureau of Aging is 
demonstrating the extent to which more effective case management and im- 
proved linkages between community-based and acute care providers will im- 
prove services for older persons. 

(Jf) National Long Term Care Resource Centers 

Six (6) National Aging Resource Centers on Long Term Care were supported by 
the Administration on Aging in fiscal year 1989, 1990, and 1991 under three year 
cooperative agreement awards to provide training and technical information to 
State and Area Agencies on Aging to assist them in developing community-based 
long term care service systems. Each Center focused on a specific set of topics 
within the broad scope of long term care. All Centers were active for some portion 
of calendar year 1992. Two university-based Center grantees successively competed 



126 



for National Eldercare Institute grants in 1991 — the University of South Florida 
and the University of Southern California. Two other organizations, Brandeis Uni- 
versity and the National Association of State Units on Aging, which individually 
had Long Term Care Centers are partners in one of the two National Eldercare In- 
stitutes on Long Term Care. 

The National Long Term Care Resource Center on State Management of 
Community-Based Care Systems operated by the National Association of State 
Units on Aging (NASUA) (Washington, DC) assisted State Units on Aging in 
design and management of community based care systems with emphasis on 
policy, operation, and management issues. Issues areas addressed in its publica- 
tions include case management, targeting criteria, State and local administra- 
tive structures, financing mechanisms, quality assurance, supportive in-home 
services, and linkage of long term care systems to systems delivering acute, pri- 
mary and institutional care. These topics are currently addressed by the Na- 
tional Eldercare Institute on Long Term Care conducted by NASUA with par- 
ticipation of Brandeis University. 

The Bigel Institute at Brandeis University (Waltham, MA) directed the Na- 
tional Aging Resource Center: Long Term Care from fiscal year 1989-1992. It 
provided training and technical assistance to State and Area Agencies on Aging 
in the areas of community-based long term care, public and private partner- 
ships, and cultural diversity and other emerging issues related to the long term 
care workforce. 

The Long Term Care National Resource Center at UCLA/USC was a collabo- 
rative effort between the Division of Geriatric Medicine and Gerontology at the 
University of California, Los Angeles, and the Andrus Gerontology Center at 
the University of Southern California (Los Angeles, California). The Center fo- 
cused on five long term topics in the area of housing and health systems devel- 
opment, including: home repair and modification, assisted-housing alternatives, 
respite care, discharge planning, and geriatric assessment. Publications of the 
Center are available through the new National Eldercare Institute on Housing 
and Supportive Services at the Andrus Center and through the Division of Med- 
icine and Gerontology at UCLA. 

The National Resource Center on Alzheimer's Disease managed by the Sun- 
coast Gerontology Center, University of South Florida (Tampa, FL), focused on 
activities and programs affecting the care of Alzheimer's patients and their 
family caregivers. Among the publications available through the new National 
Eldercare Institute on Long Term Care and Alzheimer's Disease at the Suncoast 
Center, are training syllabi, technical assistance manuals and guides for reach- 
ing minority caregivers, caring for Alzheimer's patients, establishing respite 
care and registry programs, and designing special care units in nursing homes. 

The Long Term Care DECISIONS Center established at the School of Public 
Health, University of Minnesota (Minneapolis, Minnesota), focused on the devel- 
opment of case management systems and the ethics of management and care- 
giving of long term care services. Publications of the Center, including issue 
papers developed for working conferences on family care giving, assessment of 
value and preferences of clients, ethics and case management, and the rights of 
elderly to assume risk in choosing formal care options, and an ethics catalog for 
long term care practitioners is available from the School of Public Health. 

The Heartland Center on Aging, Disability and Long Term Care sponsored by 
the National Center for Senior Living (South Bend, IN) and located at the 
School of Public and Environmental Affairs, Indiana University at Indianapolis, 
focused on needs assessment and data analysis in the Aging Network, with spe- 
cial emphasis on documenting the unmet needs of special sub-populations of the 
elderly, and functional disabled. Publications of the Center, which include user- 
oriented descriptions of national data sets and manuals on development and use 
of needs assessment instruments, are available through the School of Public 
and Environmental Affairs. 

(5) Reaching the Elderly in Rural Areas 

The National Resource Center for Rural Elderly conducted by the University of 
Missouri (Kansas City, MO) provided technical assistance training, information dis- 
semination, and short-term research and developmental efforts to support States, 
communities, educational institutions, professionals in the field and the public in 
understanding and responding to issues affecting the rural elderly. The Center iden- 
tified best-practice programs and services for the rural elderly in three primary 
focus areas — access/transportation, health/care coordination, and housing/assisted 



127 



living alternatives. Publications on such topics as advocacy and fundraising, housing 
programs, the future of aging in rural America, cooperative extension network and 
the rural elderly; and caregiving for frail elders in rural America are available 
through the university. 

g. Encouraging Business to Address Needs of the Vulnerable Elderly 

The aging of our society has not gone unnoticed by the business community. The 
mature market for consumer goods and services is one of the most rapidly expand- 
ing areas of our economy. The Administration on Aging maintains an active inter- 
est in this discovery of aging by private enterprise and solicits their participation in 
the goals of the National Eldercare Campaign to encourage a focus on development 
of goods and services supporting the needs of the more vulnerable elderly. In addi- 
tion to support of the National Eldercare Institute on Business and Aging described 
earlier, has recently supported research and innovation projects in small business 
and continued its participation in the National Energy and Aging Consortium. 

(a) Small Business and Aging 

The market for goods and services for vulnerable non-institutionalized elderly is 
especially suited for small businesses who are willing to take risks that larger com- 
panies will not until market information supports their capital investment. The Ad- 
ministration on Aging has been a participant in Small Business Innovation Re- 
search Program coordinated by the U.S. Small Business Administration since fiscal 
year 1990 and was active in its support in 1992. 

In fiscal year 1992, support was given to three new contracts under the Small 
Business Innovative Research Program, an activity coordinated by the U.S. 
Small Business Administration. These Phase I contracts address applications of 
technology to meet the needs of older persons for devices which assist them to 
perform tasks of daily living. Projects supported are as follows: 

TechnoView, Inc. (Newport Beach, CA) to establish the technical feasibility 
for developing an Intravenous Drug Delivery Monitor for use by elderly pa- 
tients being treated for serious diseases at home via home health care service 
providers and family members when nurses are not present. 

American Research Corporation of Virginia (Radford, VA) is developing the 
specifications for a personal communication system to permit caregivers to mon- 
itor the well-being of homebound elderly family members. 

Kinophase, Inc. (Nashua, NH) is developing a visual/audio system that will 
investigate the use of a kinoform lens to overcome the effects of macular degen- 
erative visual problems often found among the elderly. 

Also in fiscal year 1992, grant award support was given to the Delaware Divi- 
sion of Aging (New Castle, DL) to establish a partnership with the Delaware 
Development Office to better address the eldercare needs of small businesses in 
rural Delaware. By establishing a network at the community level with small 
businesses, the project will channel eldercare information to employers and em- 
ployees and to advocate for the development of work/family policies within 
small businesses. 

In fiscal year 1991, support was given for Phase II contracts under the Small 
Business Innovative Research Program following-up on Phase I contracts 
awarded by AoA in fiscal year 1990. These contracts are as follows: 

Gil-Mart Enterprises (San Antonio, TX) for the continued development of an 
affordable personal hygiene system which will enable the disabled elderly to 
maintain personal cleanliness independently of the caregiver. 

Triangle Research and Development Corporation (Research Triangle Park, 
NO for the construction of a unique air-mattress system for the prevention of 
decubiti and the enhancement of blood circulation. 

Gibson-Hunt Associates (Washington, DC) for a detailed plan for educating 
professionals on the need for self-help devices for the elderly will continue with 
a national, live interactive teleconference on independence of the elderly and a 
video edited from the teleconference, along with study materials for publication 
and dissemination. 

(b) Public Private Partnerships 

AoA has been engaged for a number of years in promoting public/private partner- 
ships. In late fiscal year 1990 AoA made thirteen (13) awards to State and Area 
Agencies on Aging to generate new resources or to expand existing resources to 
meet the needs of older persons by supporting the development of new or expanded 
public /private partnerships. Support was sought to enhance or sustain community 
agencies and programs in areas of senior employment and training, work site Elder- 



128 



care programs, adult day, medication management, and rural health services. A 
grant to the Washington Business Group on Health (Washington, D.C.) which now 
serves as the National Eldercare Institute on Business and Aging was supplemented 
to give these projects technical assistance. 

Sonoma County Area Agency on Aging (Santa Rosa, CA) expanded its Older 
Worker Network by establishing a senior mentor program which will match re- 
tired volunteers with job seekers over age 55 who have basic educational defi- 
ciences and language barriers. 

Fairfax County Area Agency on Aging (Fairfax, VA) added private sector job 
placements to its existing public sector job placement program of its Senior 
Training Employment Program and developing written and audio-visual materi- 
als documenting supervision, data collection and evaluation instruments used in 
operating the program. 

New York City Department for the Aging (New York, NY) with support from 
the International Business Machines Corporation expanded an existing senior 
employment services program by offering underemployed or unemployed older 
workers basic computer and office skills training and placement. 

Philadelphia Corporation for Aging (Philadelphia, PA) developed a coalition 
of local companies and the Chamber of Commerce to assist older workers and 
retirees with the goal of increasing corporate involvement in issues and in pro- 
grams of the aging workforce and marketplace. 

Suffolk County Department for the Aging (Hauppauge, NY) formed a partner- 
ship of corporations and unions to develop and operate two model elderly social 
day-care centers with intergenerational programming. 

Westchester County Office for the Aging (White Plains, NY) worked with the 
International Business Machine Corporation to establish a tax exempt, non- 
profit organization to raise revenues; and to develop and operate a service deliv- 
ery model for the rural portion of the county that includes support services and 
transportation for isolated home-bound frail elderly. 

Southern Maine Area Agency on Aging (Portland, MA) enrolled ten area 
businesses to support an Eldercare Specialist to expand the capacity of private 
sector employers to support working caregivers. 

Maryland Office on Aging (Baltimore, MD) added to its Senior Reach Part- 
ners Program, a coalition of corporate and private non-profit organizations, a 
family care network program to assist employees and retirees in caring for 
acutely or chronically ill family members. 

Jefferson County Office of Senior Citizens' Activities (Birmingham, AL) 
worker with a coalition of academic, corporate, voluntary, and government or- 
ganizations to demonstrate a medication management systems for elderly resi- 
dents of forty-four (44) county domiciliary houses. 

Los Angeles Department of Aging (Los Angeles, CA) formed a coalition of cor- 
porate and public organizations to create an Eldercare program which will pro- 
vide training, referral, and structuring of employee benefit packages as services 
to employees caring for frail elderly. 

Delaware Department of Health and Social Services (New Castle, DL) worked 
with the State Chamber of Commerce to develop information packages, employ- 
ees seminars, and employer workshops to increase access of employees and their 
families to community and in-home services. 

Puerto Rico Governor's Office of Elderly Affairs (San Juan, PR) and Smith, 
Kline and French Pharmaceutical collaborated to offer health evaluation and 
referral services in eight (8) rural areas and give supportive services to heath 
promotion self-help groups. 

County of Orange Area Agency on Aging (Santa Ana, CA) revitalized a non- 
profit foundation devoted to supporting nutrition and supportive services by as- 
sisting fund solicitation and public education. 

(c) National Energy and Aging Consortium 

The National Energy and Aging Consortium (Washington, DC) is a coalition of na- 
tional public and private sector organizations concerned about the energy related 
needs of the elderly. Energy related needs are defined in the broadest terms to in- 
clude such issues as housing, assistive devices in the home, and low income energy 
assistance. AoA continues to take an active role in the Consortium and serves as a 
member of the Steering Committee. Technical assistance materials funded under a 
fiscal year 1990 grant to the University of Oklahoma (Norman, Oklahoma) were dis- 
tributed during 1992 and a January 1992 Dissemination Conference was held. 



129 



h. Sharing Experiences With the International Community 

During 1992, the Administration on Aging continued to participate in internation- 
al aging activities, including the following: 

Participation in planning for the newly created United States- Japan Commis- 
sion on Aging established by the United States and the Japanese Governments. 
This Commission will address a wide range of long-term care issues of interest 
to both countries. 

Cooperation with the U.S. State Department, the National Institute on Aging, 
and other national organizations, in serving as a host to a number of individual 
and group delegation visits from other countries interested in U.S. aging poli- 
cies, including Canada, Mainland China, Japan, South Africa, and Sweden. 

Partial funding support and participation in the International Conference on 
Population Aging, held in San Diego, California in September 1992. The Confer- 
ence was co-organized by various United Nations divisions in response to the 
Tenth Anniversary of the Vienna International Plan of Action on Aging. AoA 
support was provided through the San Diego State University Center on Aging 
which has served as the AoA supported National Aging Resource Center on Mi- 
nority Populations. The Conference was a forum for policy makers, planners 
and scholars around the world to discuss issues on population aging and to 
present conclusions and recommendations for upcoming United Nations assem- 
blies to consider. The Deputy Commissioner on Aging addressed the Conference 
which was attended by over 350 individuals, including United Nations officials. 

SOCIAL SECURITY ADMINISTRATION 

Programs Administered by the Social Security Administration — Fiscal Year 

1992 

The Social Security Administration (SSA) administers the Federal old-age, survi- 
vors, and disability insurance (OASDI) program (title II of the Social Security Act). 
OASDI is the basic program in the United States that provides income to individ- 
uals and families when workers retire, become disabled, or die. The basic idea of the 
cash benefits program is that, while they are working, employees and their employ- 
ers pay Social Security taxes; the self-employed also are taxed on their net earnings. 
Then, when earnings stop, or are reduced because of retirement in old-age, death, or 
disability, cash benefits are paid to partially replace the earnings that were lost. 
Traditionally, current taxes have largely been paid out in current benefits. Social 
Security taxes are deposited to the Social Security trust funds and are used only to 
pay Social Security benefits and administrative expenses of the program. Amounts 
not currently needed for these purposes are invested in interest bearing obligations 
of the United States. Thus, current workers help to pay current benefits and, at the 
same time, build rights to future benefits. 

SSA also administers the Supplemental Security Income (SSI) program for needy 
aged, blind, and disabled people (title XVI of the Social Security Act). SSI provides a 
federally financed floor of income for eligible individuals with limited income and 
resources. SSI benefits are financed from general revenues. In about 52 percent of 
the cases, SSI is reduced due to individuals' having countable income from other 
sources, including Social Security benefits. 

SSA shares responsibility for the black lung program with the Department of 
Labor. SSA is responsible, under the Federal Coal Mine Health and Safety Act, for 
payment of black lung benefits to coal miners and their families who applied for 
those benefits prior to July 1973 and for payment of black lung benefits to certain 
survivors of miners. 

Local Social Security offices process applications for entitlement to the Medicare 
program and assist individuals with questions concerning Medicare benefits. Overall 
Federal administrative responsibility for the Medicare program rests with the 
Health Care Financing Administration, HHS. 

Following is a summary of beneficiary data and selected administrative activities 
for Fiscal Year 1992. 

I. OASDI Benefits and Beneficiaries 

At the beginning of 1992, about 96 percent of all jobs were covered under the 
Social Security program. It is expected that, under the present law, this percentage 
of jobs will remain constant through the end of the century. The major groups of 
workers not covered under Social Security are Federal workers hired before Janu- 



130 



ary 1, 1984 and State and local government employees for whom the State has not 
elected Social Security coverage. 

At the end of September 1992, 41.3 million people were receiving monthly Social 
Security cash benefits, compared to 40.4 million in September 1991. Of these benefi- 
ciaries, 25.7 million were retired workers, 3.5 million were dependents of retired 
workers, 4.8 million were disabled workers and their dependents, 7.3 million were 
survivors of deceased workers and about 4,000 were persons receiving special bene- 
fits for uninsured individuals who reached age 72 some years ago. (The cost of these 
special benefits for aged uninsured persons is financed from general revenues, not 
from the Social Security trust funds.) 

The monthly amount of benefits paid for September 1992 was $23.9 billion, com- 
pared to $22.5 billion for September 1991. Of this amount, $16.4 billion was paid to 
retired workers and their dependents, $2.6 billion was paid to disabled workers and 
their dependents, $4.9 billion was paid to survivors, and $1 million was paid to unin- 
sured persons who reached age 72 in the past. (The cost of these special benefits for 
aged uninsured persons is financed from general revenues, not from the Social Secu- 
rity trust funds.) 

Retired workers received an average benefit for September 1992 of $632 (up from 
$605 in September 1991), and disabled workers received an average benefit of $607 
(up from $587 in September 1991). Retired workers newly awarded Social Security 
benefits for September 1992 averaged $600, while disabled workers received an aver- 
age initial benefit of $601. 

During the 12 months ending September 1992, $282 billion in Social Security cash 
benefits were paid, compared to $263 billion for the same period last year. Of that 
total, retired workers and their dependents received $193.9 billion, disabled workers 
and their dependents received $30.4 billion, survivors received $57.4 billion, and un- 
insured beneficiaries over age 72 received $9 million. (The cost of these special bene- 
fits for aged uninsured persons is financed from general revenues, not from the 
Social Security trust funds.) 

Monthly Social Security benefits were increased by 3.7 percent for December 1991 
(payable beginning January 1992) to reflect a corresponding increase in the Con- 
sumer Price Index (CPI). 

Monthly Social Security benefits increase by 3 percent for December 1992 (pay- 
able beginning January 1993) to reflect a corresponding increase in the CPI. 

II. Supplemental Security Income Benefits and Beneficiaries 

In January 1992, SSI payment levels (like Social Security benefit amounts) were 
automatically adjusted to reflect a 3.7-percent increase in the CPI. From January 
through December 1992, the maximum monthly Federal SSI payment level for an 
individual was $422. The maximum monthly benefit for a married couple, both of 
whom were eligible for SSI, was $633. In January 1993, these monthly rates increase 
to $434 for an individual and $652 for a couple, to reflect a 3-percent increase in the 
CPI. 

As of June 1992, 5.4 million aged, blind, or disabled people received Federal SSI or 
federally administered State supplementary payments. Of the 5.4 million recipients 
on the rolls during June 1992, about 2.1 million were aged 65 or older. Of the recipi- 
ents aged 65 or older, about 623,600 were eligible to receive benefits based on blind- 
ness or disability. About 3.3 million recipients were blind or disabled and under age 
65. During June 1992, Federal SSI benefits and federally administered State supple- 
mentary payments totaling nearly $1.9 billion were paid. 

For fiscal year 1992, an estimated $21.3 billion in benefits (consisting of $17.8 bil- 
lion in Federal funds and $3.5 billion in federally administered State supplementary 
payments) were paid. 

III. Black Lung Benefits and Beneficiaries 

Although responsibility for new black lung miner claims shifted to the Depart- 
ment of Labor (DOL) in July 1973, SSA continues to pay black lung benefits to a 
significant, but gradually declining, number of miners and survivors. (While DOL 
administers new claims taken by SSA under part C of the Federal Coal Mine Health 
and Safety Act, SSA is still responsible for administering part B of the Act.) 

During September 1992, about 184,000 individuals (143,000 age 65 or older) re- 
ceived $67 million in black lung benefits which were administered by the Social Se- 
curity Administration. These benefits are financed from general revenues. Of these 
individuals, 37,000 miners received $14.5 million, 106,000 widows received $43 mil- 
lion, and 41,000 dependents and survivors received $9.5 million. During fiscal year 



131 



1992 SSA administered black lung payments in the amount of $826 million. About 
37,000 miners and 106,000 widows and wives were age 65 or older. 

Black lung benefits increased by 4.2 percent effective January 1992 due to an 
automatic general benefit increase adjustment under the law. The monthly payment 
to a coal miner disabled by black lung disease increased from $387.10 to $403.30. 
The monthly benefit for a miner or widow with one dependent increased from 
$580.60 to $605.00 and with two dependents from $677.40 to $705.80. The maximum 
monthly benefit payable when there are three or more dependents increased from 
$774.10 to $806.60. 

IV. Communication and Services 

In 1992, SSA continued to direct public information efforts to both its 45 million 
j beneficiaries and the 135 million workers currently paying into the system. SSA em- 
! phasized how the programs work, the benefits and services available, and the finan- 
cial soundness of Social Security. 

In 1992, SSA released a multi-media public information campaign to help instill 
public confidence in Social Security. Public Service Announcements (PSA's) were 
sent to about 675 television stations, 5,000 radio stations, and 3,000 national con- 
sumer magazines across the country. Using the tagline, "Social Security . . . there's 
safety in our numbers," the campaign stresses the financial soundness of the system 
and encourages people to learn more about what their Social Security tax dollars 
are buying. 

SSA also produced and distributed nationally television and radio PSA's that ad- 
dressed such topical concerns as Social Security benefits for people with AIDS and 
HIV disease, Supplemental Security Income (SSI) benefits for children with disabil- 
ities, and the SSA toll-free telephone service. 

A series of "live-read" radio spots in 60-, 30-, and 15-second formats called "Just a 
Minute . . . With Social Security," was inaugurated in 1992 and distributed to 
5,000 radio stations twice during the year. The spots cover a variety of Social Securi- 
ty topics and will be released three times a year. 

In 1992, SSA launched an outreach campaign designed to stress to farmers, crew 
leaders, and farm labor contractors their responsibility to match farmworkers' FICA 
taxes and to make accurate wage reports to SSA for the farmworkers they hire. 
Working with IRS and the Department of Labor, SSA prepared and distributed two 
bilingual (English and Spanish) booklets — one targeted to farmers and farm labor 
contractors and the other directed to farmworkers. 

Also in 1992, SSA launched a newsletter for major employers called "The Social 
Security Reporter." When the premier edition met with much success, SSA and IRS 
collaborated to produce a joint newsletter — the "SSA /IRS Reporter." The publica- 
tion is intended to keep employers up to date on Social Security and IRS policies 
and procedures that affect them — especially their personnel and payroll depart- 
ments. It will be sent twice a year to 6 million employers who file quarterly taxes. 

SSA also produced two posters that were distributed to major employers across 
the country. One poster, intended to be displayed in payroll divisions, reminds them 
of the importance of accurate wage reporting. The other poster, geared to employ- 
ees, encourages them to use SSA's "Personal Earnings and Benefit Estimate State- 
ment" service to regularly check the wages reported to SSA by their employers. 

A third poster was produced to remind new brides that if they change their name, 
they should report that change to Social Security to ensure that their earnings will 
be properly recorded. They were distributed to county courthouses for display in 
marriage license bureaus and to SSA field offices for them to arrange displays at 
businesses that cater to brides. 

SSA continues to produce a wide range of publications for the public. About 50 
"consumer" booklets and factsheets keep the general public informed of the various 
Social Security programs and policies that may affect them. Most of these are also 
available in Spanish. SSA produces about 40 "administrative" publications (many in 
Spanish) that are sent with notices to Social Security beneficiaries. These pamphlets 
contain information the beneficiary needs to know so that the official notice can be 
kept shorter and easier to understand. To help people familiarize themselves with 
the publications available, two publications catalogs — one geared to external groups 
and intergovernmental organizations, the other toward Social Security field of- 
fices — were distributed, Social Security's Public Information Distribution Center, 
which was created in 1991 to facilitate access to SSA publications, responded to 
more than 16,800 requests for publications in 1992. 



132 



In 1992, SSA broadened its outreach to non-English speaking populations by pro- 
ducing a series of three program factsheets in five Pacific-Asian languages (Cambo- 
dian, Japanese, Korean, Mandarin Chinese, and Vietnamese). 

SSA continues to publish the "Social Security Courier," a free monthly camera- 
ready newsletter available in English and Spanish. More than 15,000 nonprofit and 
governmental organizations subscribe to it and reproduce and disseminate pertinent 
articles to their constituencies. 

Each year, SSA offices across the country answer millions of Social Security in- 
quiries. Additionally, many inquiries are directed to SSA's Office of Public Inquiries 
(OPI). Among these are inquiries to the President, Congress, the Secretary of HHS, 
and the Commissioner of Social Security. In FY 1992, OPI received almost 100,000 
inquiries, primarily about disability, SSI, and hearings and appeals. OPI also proc- 
essed more than 12,000 Freedom of Information Act requests. 

In 1992, SSA continued aggressive efforts to counter misleading advertising and 
deceptive marketing practices under the provisions of Section 1140 of the Social Se- 
curity Act, which prohibits misuse of symbols, emblems, or names referencing Social 
Security or Medicare. Legislation to strengthen Section 1140 was passed by both 
Houses of Congress, but was not signed into law. 

V. Summary of Legislation that Affects SSA, 1991-92 

Emergency Unemployment Compensation Act of 1991 (H.R. 3575), P.L. 102-164, 
signed November 15, 1991 
Contains a provision that requires all Federal agencies to disclose to the Depart- 
ment of Education, on a reimbursable basis, the most recent address in agency files 
of former students who have defaulted on repayment of a federally sponsored educa- 
tional loan and the name and address of the students' employer. 

Departments of Labor, Health and Human Services, and Education and Related 
Agencies Appropriations Act, FY 1992 (HR. S8S9), P.L. 102-170, signed Novem- 
ber 26, 1991 

Provides FY 1992 funding for SSA's Limitation on Administrative Expenses ac- 
count of $4,482 billion, with an additional contingency reserve of $100 million. The 
appropriation for SSI program costs is $13,929 billion, including $6 million for SSI 
outreach. 

The House Appropriations Committee report encourages SSA to determine which 
outreach approaches are most effective in reducing barriers to participation in the 
SSI program among people who are SSI-eligible. Additionally, the House report ex- 
presses concern that SSA employ a sufficient number of bilingual staff in field of- 
fices to meet the needs of non-English-speaking clients. The Senate Appropriations 
Committee report urges that the outreach funded by this appropriation include ef- 
forts to increase enrollment in the Qualified Medicare Beneficiary program. 

The reports of both the House and Senate Committees on Appropriations direct 
SSA to continue to update guidelines for disability claims involving chronic fatigue 
syndrome and to take steps to facilitate a consistent national policy for resolving 
these claims. 

Aroostook Band of Micmacs Settlement Act (S. 374), P.L. 102-171, signed November 
26, 1991 

Provides Federal recognition to the Aroostook Band of Micmacs, provides to mem- 
bers of the Band services that the United States provides to Indians because of their 
status as Indians, and establishes a $900,000 land acquisition and property tax fund. 

Payments made by the State of Maine to the Band, or any member of the Band, 
under this law are excluded from consideration in determining eligibility for, or 
computing payments under, any Federal financial aid program, including the Sup- 
plemental Security Income program. 

Tax Extension Act of 1991 (H.R. 3909), P.L. 102-227, signed December 11, 1991 

Extended until June 30, 1992, certain tax provisions that were scheduled to expire 
for tax years beginning after December 31, 1991. (For tax years beginning in 1992, 
only amounts paid before July 1, 1992 may be excluded.) 

Employer-provided educational assistance. — Extended the exclusion for income tax 
and Social Security purposes of amounts paid, or expenses incurred, by an employer 
under a qualified educational assistance program. 

Group legal services plans. — Extended the exclusion for income tax and Social Se- 
curity purposes of amounts contributed by an employer to, services received by an 
employee from, or amounts paid to an employee under, a qualified group legal serv- 
ices plan. 



133 



Older Americans Act Amendments of 1992 (H.R. 2967), P.L. 102-375, signed Septem- 
ber 30, 1992 

Contains a "Sense of the Congress" provision that the next White House Confer- 
ence on Aging (to be convened not later than December 31, 1994) consider the 
impact of the retirement earnings test on older individuals who are employed. 

Treasury, Postal Service and General Government Appropriations Act, FY 1993 (H.R. 
5488), P.L. 102-393, signed October 6, 1992 
Establishes a "Commission on the Social Security 'Notch' Issue". The 12-member 
Commission is to be made up of 4 members appointed by the President, and 2 mem- 
bers each appointed by the Majority and Minority Leaders of the Senate and the 
Speaker and Minority Leader of the House. The Commission is to conduct a compre- 
hensive study of the notch issue and to report to the Congress by December 31, 1993. 

Departments of Labor, Health and Human Services, and Education and Related 
Agencies Appropriations Act, FY 1993 (H.R. 5677), PL. 102-394, signed October 
6, 1992 

Limitation on Administrative Expenses (LAE). — The $4,899,142,000 included in the 
FY 1993 appropriations bill language for the LAE account was reduced $86,041,000 
to $4,813,101,000, in accordance with sections 216, 511 and 512 of P.L. 102-394. The 
program level funding of $4,813,101,000 includes a contingency reserve of 
$198,400,000, which is $148,400,000 more than had been requested. 
The report of the Senate Appropriations Committee: 

Directs SSA to provide by March 15, 1993 a comprehensive report addressing 
the following issues with respect to SSA's planning for future systems: the 
status of the 13 current intelligent workstation /local area network pilot 
projects, including an evaluation of the need for changes in work processes; 
evaluation costs and benefits; new approaches considered to improve services; 
and a timetable for completing the evaluation and expert advice obtained from 
the General Accounting Office (GAO), the Office of Inspector General, and the 
National Academy of Sciences in developing evaluation methodology and crite- 
ria; 

Directs SSA to explore and report to the Committee by March 30, 1993, on 
the feasibility of establishing a partnership with a not-for-profit educational 
entity to foster hands-on employee training in state-of-the-art computer infor- 
mation systems; 

Expresses concern that SSA has not taken more steps to ensure safe and 
healthful working conditions in the Security West Building, and directs the 
Commissioner of Social Security to place a high priority on improving working 
conditions and implementing an effective safety and health program for SSA 
employees; 

Directs that $650,000 be used by SSA to install telephone devices for the deaf 
in local Social Security offices, in an effort to provide equal access for deaf indi- 
viduals; and 

Requests that a collaborative team of chronic fatigue syndrome (CFS) pa- 
tients, scientists, and SSA officials meet and review current medical informa- 
tion about CFS and SSA procedures for processing CFS cases. 
The report of the House Appropriations Committee: 

Urges the Commissioner to establish a task force to address the problems of 
bilingual staffing, bilingual interpreters, assessment of bilingual service needs 
and Spanish language notices. The Committee requests that SSA report no later 
than February 1994 with recommendations and implementation plans for the 
development of a nationwide bilingual service policy and programs. 

Expresses concern that SSA has not provided future year cost estimates relat- 
ed to the Information System Plan (ISP) — the implementation plan for automa- 
tion improvements, directs that this information be submitted to the GAO for 
review, and directs that an updated ISP containing future year cost estimates 
be submitted along with the 1994 Budget Justification. 

Energy Policy Act of 1992 (H.R. 776), P.L. 102-486, signed on October 24, 1992 

Establishes a new United Mine Workers of America Combined Benefit Plan, as a 
successor to current health benefits plans for certain retired coal mine workers. The 
Secretary of Health and Human Services must: (1) assign each coal industry retiree 
who is eligible for benefits under the new Combined Benefit Plan to a current coal 
mine operator, (2) notify the fund of the operator to which each retiree is assigned, 
and (3) notify the operator (who may request reconsideration of the assignment). 
The assignment of eligible retirees must be completed before October 1, 1993. 



134 



The Secretary also must calculate the per beneficiary premium to be paid by the | 
assigned operators for each "plan year" beginning on or after February 1993. 

The legislation does not include language authorizing HHS/SSA to use current 
appropriated funds to carry out the new responsibilities, such as the costs HHS/SSA 
would incur to search its records to identify eligible retirees' coal mine employers I 
and their periods of coal mine employment. 

Housing and Community Development Act of 1992 (H.R. 533U P.L. 102-550, signed 
on October 28, 1992 

Provides for the establishment of a demonstration program, the "Safe Havens for I 
Homeless Individuals Demonstration Program," under the Stewart B. McKinney 
Homeless Assistance Act. The demonstration project will provide housing for home- 
less mentally ill/drug-dependent individuals. The provision prohibits reduction of 
SSI benefits because of in-kind support and maintenance received through the dem- i 
onstration program. 

OFFICE OF INSPECTOR GENERAL 
Introduction 

The mission of the Office of Inspector General (OIG) is to prevent and detect 
fraud, waste, and abuse in the Department of Health and Human Services (HHS) 
programs and to promote efficiency and economy in its operations. It is the Inspec- 
tor General's responsibility to report to the Secretary and the Congress any deficien- 
cies or problems relating to HHS programs and to recommend corrective action, 
where appropriate. 

As a result of a congressional oversight initiative into disclosures of fraud and 
waste in Federal/State Medicaid and welfare programs, Public Law 94-505 was 
passed, creating the statutory Inspector General in HHS. Enacted in 1976 the law 
placed equal emphasis on the Inspector General's obligation to detect wrong-doing 
and to make recommendations for changes and improvements in HHS programs. 

The OIG works in a coordinated, cooperative way with other departmental compo- 
nents to accomplish its mission, except when the Inspector General believes that 
such a relationship would compromise the integrity and independence of the office. 
Close working relationships are established with the Social Security Administration 
(SSA), the Health Care Financing Administration (HCFA), the Administration for 
Children and Families (ACF) and the Public Health Service (PHS) and with other 
major Federal agencies, such as the Department of Justice (DOJ) and the Govern- 
ment Accounting Office (GAO), to maximize resources devoted to common problems. 
Governmentwide problems are addressed with other Government agencies through 
the President's Council on Integrity and Efficiency (PCIE). 

The OIG is divided into three components: The Office of Audit Services (OAS), the 
Office of Investigations (OI), and the Office of Evaluations and Inspections (OEI). 
The OAS is responsible for conducting audit services for HHS and overseeing audit 
work done by others. This component also examines the performance of HHS pro- 
grams and/or its grantees and contractors in carrying out their respective responsi- 
bilities. 

The OI reviews and investigates all allegations of a potentially criminal, civil, or 
administrative nature involving HHS programs or beneficiaries. In addition, OI is 
responsible for imposing administrative sanctions, including civil monetary penal- 
ties, on health care providers participating in the Medicare and Medicaid programs. 
Also, OI monitors the State Medicaid Fraud Control Unit (SMFCU) program, which 
was created to improve detection and eliminate fraud in the State run Medicaid pro- 
grams. 

The OEI conducts evaluations and inspections of Department programs and oper- 
ations. These are usually short-term studies designed to focus on issues of current 
interest to Department officials or Members of Congress which highlight a pro- 
gram's efficiency or effectiveness. The Immediate Office of the Inspector General is 
responsible for setting OIG policy and direction, handling budgetary and adminis- 
trative functions, reviewing and developing legislative and regulatory proposals and 
carrying out public affairs and Congressional Liaison responsibilities. 

These audit, inspection and investigative activities focus on: 

— Seeking ways to improve fiscal controls in benefit payment processes; 

— Seeking ways to enhance trust fund financial management and accounting op- 
erations; 

— Identifying more efficient and economical improvements in programs, procure- 
ment and service delivery, including reviews of the appropriateness of Federal 
payments of services provided and for the quality of care received; and 



135 



— Reducing the incidence of fraud, waste, and abuse in the Department's pro- 
grams and to the Department's beneficiaries. 

Activities 

Over the past 5 years the OIG has obtained over $29.8 billion in settlements, 
fines, restitutions, receivables, and savings from its activities and implementation of 
its recommendations. In fiscal year 1992 alone, these types of savings exceeded $5.9 
billion. In addition, a total of 1,893 individuals and entities were convicted for en- 
gaging in crimes against HHS programs or beneficiaries and 1,739 health care pro- 
viders and suppliers or their employees were administratively sanctioned in fiscal 
year 1992. 

In addition to audit and investigative work, the OIG reviewed 211 departmental 
draft regulations, commented on 393 legislative proposals and testified on 17 occa- 
sions before congressional committees. 

Following under the headings, Health Care, Social Security, and Administration 
on Aging, are examples of OIG reviews conducted in fiscal year 1992 that have sub- 
stantial impact on the elderly: 

OFFICE OF THE ASSISTANT SECRETARY FOR PLANNING AND 
EVALUATION 

The Office of the Assistant Secretary for Planning and Evaluation (ASPE) serves 
as the principal advisor to the Secretary on policy and management decisions for all 
groups served by the Department, including the elderly. ASPE oversees the Depart- 
ment's legislative development, planning, policy analysis, and research and evalua- 
tion activities and provides information used by senior staff to develop new policies 
and modify existing programs. 

ASPE is involved in a broad range of activities related to aging policies and pro- 
grams. It manages grants and contracts which focus on the elderly and coordinates 
other activities which integrate aging concerns with those of other population 
groups. For example, the elderly are included in studies of health care delivery, pov- 
erty, State-Federal relations and public and private social service programs. 

ASPE also maintains a national clearinghouse which includes aging research and 
evaluation materials. The ASPE Policy Information Center (PIC) provides a central- 
ized source of information about evaluative research on the Department's programs 
and policies by tracking, compiling and retrieving data about on-going and complet- 
ed HHS evaluations. In addition, the PIC database includes reports on ASPE policy 
research studies, the Inspector General's program inspections and investigations 
done by the General Accounting Office, the Congressional Budget Office and the 
Office of Technology Assessment. Copies of final reports of the studies described in 
this report are available upon completion from PIC. 

During 1992, staff of the Office of the Assistant Secretary for Planning and Eval- 
uation undertook or participated in the following analytic and research activities 
which had a major focus on the elderly: 

1. Policy Development — Aging 
task force on elder abuse 

During 1992, ASPE and the Administration on Aging (AoA) co-chaired the Secre- 
tary's Task Force on Elder Abuse that also includes the Health Care Financing Ad- 
ministration, the Public Health Service and the Social Security Administration. The 
Task Force developed a Departmental plan to promote the prevention and improved 
reporting, investigation and follow-up of elder abuse. 

The plan recommended that the Department implement the following strategies: 
(1) Develop and fund a national research and data collection strategy on elder 
abuse, (2) Develop and fund a technical assistance and training program on elder 
abuse, and (3) Develop and promote targeted public education activities on elder 
abuse. The Task Force began to implement these activities throughout 1992. 

TASK FORCE ON ALZHEIMER'S DISEASE 

As a member of the DHHS Council on Alzheimer's Disease, each year ASPE helps 
prepare the annual report to the Congress on selected aspects of caring for persons 
with Alzheimer's disease. The report focuses on the Department's current and 
planned services research initiatives on Alzheimer's disease. 



136 



FEDERAL INTERAGENCY FORUM ON AGING-RELATED STATISTICS 

ASPE is a member of the Federal Interagency Forum on Aging-Related Statistics 
(the Forum). The Forum was established to encourage the development, collection, 
analysis, and dissemination of data on the older population. The Forum seeks to 
extend the use of limited resources among agencies through joint problem solving, 
identification of data gaps and improvement of the statistical information bases on 
the older population that is used to set the priorities of the work of individual agen- 
cies. 

DEPARTMENTAL DATA PLANNING AND ANALYSIS WORKING GROUP 

The Data Planning and Analysis Working Group chaired by ASPE analyzes De- 
partmental data requirements and develops plans minimizing barriers to full utili- 
zation of such data. The Group identifies needs for data within HHS, evaluates the 
capacity of current systems to meet these needs and prepares recommendations for 
ensuring effective and efficient performance of HHS data systems. 

LONG-TERM CARE MICROSIMULATION MODEL 

During 1992 ASPE continued to use extensively the Long-Term Care Financing 
Model developed by ICF, Inc. and the Brookings Institute. The model simulates the 
utilization and financing of nursing home and home care services by a nationally 
representative sample of elderly persons for the period 1986 to 2020. It gives the De- 
partment the capacity to simulate the effects of various financing and organization- 
al reform options on future public and private expenditures for nursing home and 
home care services. During 1992, ASPE continued work on making the model avail- 
able to the general research community. 

2. Research and Demonstration Projects 

Institute for Research on Poverty, University of Wisconsin 
Robert M. Hauser, Principal Investigator. 

A research agenda of diverse but interrelated two-year studies concerned with the 
relationships between poverty and family structure, education and social welfare, 
child support and paternity, labor force behavior, and welfare dependence. In the 
1991-93 biennium there are no projects dealing exclusively with the elderly. Howev- 
er, the Institute does do a number of activities and publishes a number of materials 
on poverty which include the elderly as an important subgroup. 

Funding: Fiscal years 1991-1993— $3,000,000; End Date: June 1993. 

Panel Study of Income Dynamics 

University of Michigan, Institute for Social Research, James N. Morgan, Greg J. 
Duncan, and Martha S. Hill, Principal Investigators. 

Through an interagency consortium coordinated by the National Science Founda- 
tion (NSF contributes approximately $1.5 million per year), ASPE assists in the 
funding of the Panel Study of Income Dynamics (PSID). This is an ongoing national- 
ly representative longitudinal survey that began in 1968 under the auspices of the 
Office of Economic Opportunity. The PSID has gathered information on family com- 
position, attitudes, employment, sources of income, housing, mobility, and a host of 
other subjects every year since then on a sample of approximately 5,000 families 
and has followed all original sample members that have left home. The current 
sample size is over 7,000 families. The data files have been disseminated widely and 
are used by hundreds of researchers both within this country and in numerous for- 
eign countries to get an accurate picture of changes in the well-being of different 
demographic groups including the elderly. 

Funding: ASPE (and HHS precursors)— FY67 through FY79— $10,559,498; FY80— 
$698,952; FY81— $600,000; FY82— $200,000; FY83— $250,999; FY84— $550,000; 
FY85— $300,000; FY86— $225,000; FY87— $250,000; FY88— $250,000; FY89— $250,000; 
FY90— $300,000; FY91— NA. 

Survey of Consumer Finances 

University of Michigan, Survey Research Center, Richard Curtain, Principal In- 
vestigator. 

The Survey of Consumer Finances interviewed a representative sample of U.S. 
families in the spring of 1983 gathering a detailed accounting of family assets and 
liabilities; questioning also covered financial behavior and attitudes, work status, job 
history, and expected benefits from pensions and Social Security. A supplemental 



137 



instrument gathered information on the pension entitlement of individuals in the 
sample. Detailed descriptions of pension plans are being linked to household files. 

Data from the survey are expected to be widely used for investigation of the dis- 
tribution of holdings on various assets and liabilities, of net worth, and of entitle- 
ment to pension and Social Security benefits. In addition, these data will support 
research on financial behavior of individuals and on the effect of Social Security 
and pensions on the holdings of other assets. 

The survey was jointly sponsored by the Board of Governors of the Federal Re- 
serve System, the Department of Health and Human Services, the Department of 
the Treasury, the Federal Deposit Insurance Corporation, the Federal Trade Com- 
mission, and the Department of Labor. 

The Survey Research Center completed the second wave of the survey. Follow-up 
telephone interviews with respondents from the first survey were conducted updat- 
ing basic information from the original wave and adding new areas of questioning. 
Data from this wave will be available winter 1988. A third in-person wave will be 
conducted in 1989 to obtain another household balance sheet for those in the origi- 
nal sample, supplemented by an additional sample of households. 

Funding: ASPE— $1,012,096; Total— $1,711,983; Funding by FY: 82— $750,000; 83— 
$132,096; 84— $130,000; 89— $50,000; 90— $50,000; 91— $50,000. 

Research to Improve the Accuracy of Long-Term Forecasts of the Social Security and 
Medicare Trust Funds 

Unicon Research Corp., Finis Welch and Kevin Murphy, Principal Investigators. 

The research consists of two related projects. The first will estimate historical real 
wage growth using household data for the Current Population Survey for the period 
1964 to 1987 and forecast future growth. The goals is to decompose past wage 
growth into growth in the wages of workers with fixed characteristics and changes 
in aggregate wage levels generated by changes in the composition of hours worked. 
The project will also forecast the future distribution of workers across groups (dis- 
tinguished by sex, race, age, education, and labor force status) which will be com- 
bined with estimated relative wage patterns to forecast the composition component 
of future wage growth. 

The second project extends the analysis to evaluate the impact of changes in the 
relative earnings of husbands and wives on the solvency of the Social Security 
system. The goal is to provide estimates of the tax contributions and benefits pay- 
ments of women eligible for both primary and spouse benefits. Although prelimi- 
nary work indicates that increases in earnings and labor force participation of 
women will contribute to the solvency of the Social Security Trust Fund, the magni- 
tude depends on how the increased earnings are distributed among those already 
working and previous nonparticipants. 

Funding: FY 1989— $87,600; End Date: March 1992. 

Pensions, Savings, Health Expenditures, Long-Term Care, and Retirement 

1. "Retiree Health Insurance: A Research Proposal." 

National Bureau of Economic Research, Principal Investigators: Alan L. Gustman 
and Thomas L. Steinmeier. 

The researchers will use several data sets to estimate the change in the value of 
health insurance resulting from retirement. Using these estimates the investigators 
will expand their previous work on the effects of pensions and Social Security on 
retirement to include the effect of retiree health benefits on the retirement decision. 

Funding: FY 1990— $89,827; End Date: September 1992. 

2. "Retiree Health Benefits and the Retirement Decision." 

North Carolina State University, Principal Investigators: Robert L. Clark and 
Alvin E. Headen, Jr. 

The researchers will use data from the 1988 Employee Benefits Survey and the 
1988 Current Population Survey to examine the decision of employers to provide re- 
tiree health insurance and pensions plans. They will explore the potential tradeoffs 
between the two fringe benefits. An economic model of why workers and firms nego- 
tiate retiree health care plans will be developed and used in the derivation and 
analysis of employer-sponsored retiree health insurance coverage rates for retirees 
and for older active workers by various worker and firm characteristics. 

Funding: FY 1990— $77,429; End Date: September 1992. 

3. "Retiree Health Benefits: An Analysis of Access and Participation." 
The Urban Institute, Principal Investigator: Shiela Zledewski. 

The researchers will use the August 1988 Current Population Survey to examine 
the distribution of employer-based retiree health insurance benefits (by occupation, 
income, health, location, family status etc.) and examine the determinants of retiree 
participation in employer-based plans. The project will also estimate the value of 



138 



the employer-provided health benefits and examine their effect on retirement 
income security and government programs. 
Funding: FY 1990— $120,395; End Date: September 1992. 

Policy Aspects of Intergenerational Support for Elderly Persons 
Brown University, Principal Investigator: Alden Speare, Jr. 

The researchers will study the determinants of financial flows between elderly 
persons and children outside the household, determine the extent to which shared 
living helps the elderly avoid poverty, and examine how intergenerational transfers 
are affected by government policy. The investigators will use the Survey of Income 
and Program Participation and the Survey of Consumer Finances. 

Funding: FY 1990—163,426; End Date: September 1992. 

Health and Retirement Study 

University of Michigan, Survey Research Center, Principal Investigator: Tom 
Justen. 

The Survey of Health and Retirement is a new nationally representative longitu- 
dinal survey that will gather data on health and retirement issues from U.S. house- 
holds. In addition, financial and background histories will be gathered. Data from 
the survey are expected to be used for investigating how changes in the Social Secu- 
rity system and private pension systems have affected retirement plans. These data 
will support research on health care needs and costs. The survey was jointly spon- 
sored by the Department of Health and Human Services and the National Institute 
on Aging (NIA). 

Funding: NIA— FY91— $2,500,000; FY92— $2,500,000; FY93— $2,500,000. 
Funding: ASPE—FY90— $200,000; FY91— $200,000; FY92— $100,000. 

Characteristics of the Elderly Long-Term Care Population and Its Service Use 

Duke University, Center for Demographic Studies, Ken Manton, Principal Investi- 
gator. 

The project is organized into two phases. In the first year there will be an analy- 
sis of the 1982-84 National Long-Term Care Survey and the National Long-Term 
Care Channeling Demonstration data sets. The focus will be on functional transi- 
tions at advanced ages and the impacts of long-term care services on these transi- 
tions. In the second phase, additional national data bases like the Longitudinal Sup- 
plement on Aging will be examined to refine and extend the understanding of 
health and functional status changes among the impaired elderly as well as trends 
in service use. 

Funding: FY 1987— $56,933; End Date: December 1992. 

1988 National Long-Term Care Survey — Additional Activities 

Duke University, Center for Demographic Studies, Ken Manton, Principal Investi- 
gator. 

Under a grant from the National Institute on Aging (NIA), Duke University 
(through the Census Bureau) is conducting the 1988 National Long-Term Care 
Survey. Duke will produce a data file consisting of the 1982, 1984 and 1988 surveys 
linked to Medicare bill records. An additional grant jointly administered by NIA 
and the Office of the Assistant Secretary for Planning and Evaluation will support 
three supplementary activities: (a) a survey of informal caregivers, (b) a follow-back 
survey of institutionalized persons, and (c) an analysis of the effects of supply fac- 
tors on respondent use of services. 

Funding: FY 1987— $300,000; End Date: June 1992. 

Analysis and Comparison of State Board and Care Regulations and Their Effects on 
the Quality of Care in Board and Care Homes 

Research Triangle Institute, Catherine Hawes, Principal Investigator. 

As the Nation's long-term care system evolves, more emphasis is being placed on 
home and community-based care as an alternative to institutional care. Community- 
based living arrangements for dependent populations (disabled elderly, mentally ill, 
persons with mental retardation /developmental disabilities) play a major role in the 
continuum of long-term care and disability-related services. Prominent among these 
arrangements are board and care homes. 

There is a widespread perception in the Congress and elsewhere that too often 
board and care home residents are the victims of unsafe and unsanitary living con- 
ditions, abuse and neglect by operators, and fraud. There is also the perception that 
an increasing number of board and care residents are so disabled that they require 
a level of care greater than board and care operators are able to provide. 



139 



This project will analyze the impact of State regulations on the quality of care in 
board and care homes and document characteristics of board and care facilities, 
their owners and operators, and collect information on the health status, level of 
dependency, program participation, and service needs of residents. 

Funding: FY 1989— $350,000; FY 1990— $300,000; FY 1991— $400,000; End Date: 
November 1993. 

Informal Caregivers Conference 
SysteMetrics, Inc., Brian Burwell. 

This project brought together public and private sector experts to analyze re- 
search on informal caregiving, and examine public and private sector policy devel- 
opment. 

Funding: FY 1992— $200,000; End Date: November 1992. 
Descriptive Analysis of Licensed Board and Care Homes 

Department of Health and Human Services Office of the Assistant Secretary for 
Planning and Evaluation 

Robert F. Clark, Joan Turek-Brezina. 

In 1991, the National Health Provider Inventory (NHPI) included licensed board 
and care homes for the first time. This project provides preliminary findings about 
licensed board and care homes from the NHPI data including: (a) number of homes, 
(b) ownership types, (c) number and characteristics of residents and, (d) use of serv- 
ices. 

Funding: FY 1992— $50,000; End Date: November 1993. 
Post-Acute Care for Medicare Patients 

University of Minnesota, Robert Kane, Principal Investigator. 

The primary objective of this study is to describe the "natural history" of care 
received by patients with five different impairments (identified by DRG) in three 
post-acute care modalities. These modalities include home health care, skilled nurs- 
ing care, and rehabilitation. This study will not only provide a history of what care 
was delivered in which settings, but will also assess and compare outcomes and costs 
of care across settings and impairments. In addition, the study will determine the 
factors that influence hospital discharge decision-making. This study's findings may 
then be used to construct a revised payment method for post-acute care in the Medi- 
care program. 

Two sets of data will be collected. The first set will contain information from hos- 
pital discharge records and pre- and post-discharge client interviews in three U.S. 
cities. The second set will include a 20 percent national sample of Medicare acute 
care discharges to be linked with the utilization files of Medicare covered services 
provided in post-acute care settings. Data collection has been completed, and the 
analysis phase is currently underway. 

Funding: FY 1987— $500,000, FY 1988— $727,000, FY 1989— $695,335; End Date: 
March 1993. 

Evaluation of an Approach to Maintaining the Medical Currency of Rural Physi- 
cians and Hospitals 
Texas Tech, A. Bryan Spives, MD. 

OBRA '87 required the Department to explore and to test the feasibility of "re- 
quiring instructions and oversight of rural physicians . . . through use of video com- 
munications between rural hospitals and teaching hospitals" to maintain and im- 
prove the quality of delivered medical care with special emphasis of Medicare bene- 
ficiaries." This activity is to be supported jointly by HCFA and PHS, with ASPE 
responsible for support of necessary evaluation activities. This project will support 
the evaluation component. 

A two-part, 3 year effort, totaling $350,000 in evaluation, is envisioned. The first 
component, internal evaluation, will be supported through partial funding of the 
OBRA '87-required project(s). The second component, external evaluation, will be 
supported through consortium funding by PHS, HCFA, and ASPE of an independ- 
ent evaluation contract. 

Funding: FY 1991— $125,000, FY 1992— $125,000; End Date: June 1993. 

Extension of 100 Percent State Longitudinal Medicare Part B Data to 1990 
The Circle, Inc., Howard West, Principal Investigator. 

ASPE has collected 100 percent Part B data from six carriers representing 10 
States beginning in 1983. The States included are Washington, South Carolina, 
North Dakota, South Dakota, Minnesota, Indiana, Pennsylvania, Washington, D.C., 
Delaware, and parts of Maryland. The data are cleaned in a common format and 



140 



can be linked to 100 percent Part A MEDPAR data to create analytical files that 
contain both hospital and physician reimbursement. The data can support detailed 
analysis of individual procedures and can support analyses of such issues as physi- 
cian DRG's; the effects of bundling diagnostic procedures prior to the hospital stay 
into the DRG payment and others. The project adds 1988 data for all carriers to the 
longitudinal data series. 

Funding: FY 1990— $75,000, FY 1991— $20,000; End Date: June 1992. 

Assessment of the Effects of Reimbursement Policy on the Utilization of Clinical 
Laboratory Testing and the Contribution of That Testing in Patient Care 

Abt Associates, Steven T. Mennemeyer, Ph.D., Principal Investigator. 

This research project is designed to study the effect of reimbursement policies on 
the volume of clinical laboratory services delivered and on the propensity of physi- 
cians to perform testing in their own offices. In addition, this research project is in- 
tended to stimulate the development of methods for monitoring laboratory perform- 
ance in terms of patient care. At present the effects of reimbursement policy on lab- 
oratory utilization and the role of these laboratory services in the quality of patient 
care is poorly understood. There is widespread concern generated by media coverage 
and anecdotal evidence that the utilization of clinical laboratory services is not 
meeting patient needs during a period in which laboratory technology has improved 
dramatically. Addressing some of these concerns, Congress passed the "Clinical Lab- 
oratory Improvement Amendments of 1988" (CLIA-88). Although financial issues 
such as physician ownership of labs and direct payment were much debated, Con- 
gress did not act on these financial matters in the final bill. An assessment of data 
concerning the utilization of laboratory services is necessary for policymakers to 
identify strategies that best promote advances in laboratory services in order to en- 
hance patient care and maximize the effectiveness of health care expenditures. 

Funding: Fiscal year: 1889— $510,000; End Date: January 1992. 

Analysis of Multiple Surgical Bills on the Day of Surgery 

Center for Health Economics Research, Janet Mitchell, Principal Investigator. 

Medicare statistical files (BMAD) data for 1985-1988 will be examined to identify 
patients who have received bills for more than one surgery on the same day for 15 
or more high Medicare outlay surgical procedures. The contractor will first elimi- 
nate duplicate claims. The remaining claims will be sorted into three types with the 
aid of a medical consultant: (1) claims by the same surgeon for procedures made 
through the same incisions the principal procedure which are properly paid but a 
reduced rate (50%); (2) claims by the same surgeon for related procedures to the 
principal procedure which under the carrier's global fee policy should not have been 
billed separately (e.g., billing both for a hysterectomy and sewing up the wound); (3) 
claims by a different surgeon for a related procedure which could have been billed 
as an assistant-at-surgery claim; and (4) a second procedure through a separate inci- 
sion. Estimates will be made based on this topology, and with the aid of medical 
advice as to when billing patterns appear inappropriate of Medicare overpayments 
for both potential overbillings or apparent "unbundling" from surgical global fees. 

Funding: Fiscal year 1990— $90,000; End Date: June 1992. 

OFFICE OF THE SURGEON GENERAL 

The Surgeon General joined with the American Medical Association to produce 
their report "Diagnostic and Treatment Guidelines on Elder Abuse and Neglect," 
released in November 1992. The report was issued as part of the AMA's domestic 
violence initiation, for which the Surgeon General served as spokesperson. Other 
topics included in the initiative were child and spousal abuse. 

PUBLIC HEALTH SERVICE— CENTERS FOR DISEASE CONTROL 

National Center for Chronic Disease Prevention and Health Promotion 

The combined Health Information Database (CHID) — a Public Health Service in- 
formation resource — contains health information that pertains to aging. The data- 
base includes disease prevention, health promotion, and health education informa- 
tion on eye diseases and disorders, Alzheimer's disease, arthritis and musculoskele- 
tal diseases, diabetes mellitus, cholesterol, high blood pressure, digestive diseases, 
kidney and urologic disease, injury prevention, exercise, weight management, and 
stress management. Because of the nature of the subject areas, CHID is a valuable 
resource for health providers working with the elderly. CHID can be accessed 
through most library and information services. Persons who wish to access the data- 



141 



base directly can obtain a password from MAXWELL Online, BRS Division, 
Latham, NY, 1-800-345-4BRS. 

In 1990, the Aging Studies Branch in the Division of Chronic Disease Control and 
Community Intervention was established to: (1) conduct epidemiologic research, in- 
vestigations, and surveillance of selected chronic diseases and conditions in older 
adults; (2) develop and evaluate prevention strategies and demonstration projects; 
and (3) provide consultation and technical assistance to States and other agencies. 
Research and programmatic efforts are focused on musculoskeletal diseases (osteoar- 
thritis, osteoporosis), chronic neurological disease (Alzheimer's disease, Parkinson's 
disease), urinary incontinence, depression, developing measures of health status and 
quality of life, and promoting/supporting State efforts in these areas. 

Musculoskeletal diseases are prevalent and disabling chronic diseases, affecting 
approximately 37 million persons in the United States. Data indicate that 40 per- 
cent of persons 65 years and older have symptomatic musculoskeletal diseases and 
60 percent have clinical evidence of disease. Data are needed to describe the natural 
history of disease as well as to direct development of effective intervention efforts. 
CDC has three projects underway addressing these issues related to osteoporosis and 
one project in arthritis. 

Chronic neurological diseases, conditions common among the elderly, rank high in 
measures of morbidity, disability, family stress, and economic burden. For example, 
the costs due to dementias alone were estimated at $24-48 billion in 1985, and will 
increase as the population ages. However, the epidemiology of these conditions is 
poorly understood. CDC is conducting a number of research studies to better under- 
stand the epidemiology of Alzheimer's disease and Parkinson's disease. 

Urinary incontinence (UI), the involuntary loss of urine so severe as to have social 
or hygienic consequences, affects 15-30 percent of community-dwelling older people 
and at least half of all nursing home residents. UI costs are conservatively estimat- 
ed at $10.3 billion annually. UI goes largely untreated in millions of people, al- 
though a third of cases can be cured and another third helped significantly. CDC 
has determined incidence, prevalence, and remission rates for different types of UI 
in those 65 and older using National Health and Nutrition Examination Survey-Epi- 
demiologic Follow-up Study. CDC has recently funded intervention demonstration 
projects in two states and 1 university to develop and evaluate strategies to decrease 
disability due to this cause among older individuals. 

Quality of life is often thought to be more valuable than quantity of life. DCDCCI 
is working in concert with panels of experts to develop methods to assess quality of 
life in the general population. Several of these measures have been included in the 
Behavioral Risk Factor Surveillance System to access quality of life in the 48 par- 
ticipating states. 

The CDC-funded center for Health Promotion in Older Adults (CHPOA) at the 
School of Public Health, University of Washington, is focusing on the health of 
older Americans and has as its theme "Keeping Healthy Older People Healthy." 
The Group Health Cooperative Demonstration Project is evaluating a nurse, educa- 
tor health assessment followed by up to six intervention activities for those at risk. 
The Case-Control Analysis of Hip Fractures study showed cognitive dysfunction to 
be a major risk factor for hip fractures, along with poor tandem gait, poor balance, 
and impaired recovery after a displacement of balance; an intervention study of the 
effects of proper footwear is currently underway. The Movement Intervention Trial 
(MOVE-IT) is comparing the effect on gait and balance of three exercise interven- 
tions in those with mild to moderate movement impairments. A final project sur- 
veys the health care needs of older adults in Seattle Housing Authority public hous- 
ing; these data will help allocate County Health Department resources. The core 
funding provided by CDC has helped support other studies by CHPOA staff on phys- 
ical frailty, osteoporosis, and self-efficacy (the concept that one can successfully exe- 
cute the behavior required to produce a desired outcome). 

CDC provides technical and financial assistance to State health agencies for a 
wide variety of chronic disease prevention and control program activities. One of 
these programs targets the elderly in Flathead County, MT. The Successful Aging 
Program enables senior citizens to participate in planning risk factor screening and 
educational activities. The program has implemented interventions that target nu- 
trition, exercise, weight control, and stress reduction. As a result of the positive re- 
sults from these activities, the program is being disseminated throughout the State. 

Diabetes is a major contributor to morbidity and morality among persons 65 and 
older. An estimated 2,898,000, or 10 percent, of all Americans 65 years of age and 
older have diagnosed diabetes, compared with about 2 percent of all Americans 
below age 65. Each year, about 290,000 new cases of diabetes are identified among 
those who are 65 and older. In 1987, diabetes contributed to over 119,000 deaths and 



142 



i 



an estimated 1,507,000 hospitalizations among Americans 65 and older. About $5.2 
billion in direct medical costs can be attributed annually in the United States to I 
diabetes among persons 65 and older. 

During 1991, CDC's efforts have focused on the prevention of eye disease and car- 
diovascular disease associated with diabetes. All diabetes control programs funded 
through cooperative agreements with 27 state and territorial health departments 
currently address visual impairment associated with diabetes, and at least one of 
the following complications: adverse outcomes of pregnancy, lower extremity dis- 
ease, and cardiovascular disorders associated with diabetes. In 1987, among Ameri- 
cans with diabetes age 65 and older, there were 38,000 hospital discharges for non- 
traumatic amputations, and 2,720 individuals who began treatment for end-state 
renal disease. Decisions about diabetes control program directions reflect state judg- 
ments about disease burden, past program direction and interests, and existing re- j 
sources within the departmental of health. 

Breast cancer is the most commonly diagnosed cancer and the second leading 
cause of death from cancer among American women. Breast and cervical cancer 
tend to be diagnosed in advanced stages relative to advancing age. In 1991, it is pro- 
jected that 44,500 women will die of breast cancer and over half of breast cancers 
occur in older women. Breast cancer mortality could be reduced up to 30 percent, 
among women over age 50, if currently recommended screening guidelines, includ- 
ing mammography and clinical breast examinations were followed (PHS 1991). Cer- 
vical cancer mortality rates continue to decrease from 14.8/100,000 in 1973/74 to 
8.3/100,000 in 1987/88. However, in those women 50 and older, the rates are still 
significantly higher than those of women under the age of 50, 2 and 1.3, respective- 
ly. Recent data indicate that older women have not been receiving routine screening 
for cervical cancer. 

Current American Cancer Society screening recommendations for breast cancer in 
women 50 and older include annual mammography screening, annual clinical breast 
examination, and monthly self breast examination. For cervical cancer screening in 
women 50 and older, it is recommended that after three consecutive normal Papani- 
colaou tests with pelvic examinations have been conducted with normal results, 
then screening should be done based on physician discretion. 

Currently, CEC is funding eight states (California, Colorado, Michigan, Minnesota, 
New Mexico, South Carolina, Texas, and West Virginia) through the Breast and 
Cervical Cancer Mortality Prevention Act of 1990. These states target older women 
for education and screening efforts. Along with this, marketing of new Medicare 
benefits which support funding for Papanicolaou smears and screening mammogra- 
phy will occur through various channels at Federal, State, and local levels. 

National Center for Environmental Health 

The National Center for Environmental Health (NCEH) is completing a five-year 
observational study of women experiencing the climacteric. Risk factors for osteo- 
porosis are being studied. The study has shown that women have hormone-depend- 
ent bone loss before menopause and that androgens as well as estrogens may be im- 
portant in maintaining bone density in women. Data analysis for publication is in 
progress and will be completed in fiscal year 1993. 

CDC also maintains the national accuracy base for the standardization of lipid 
and lipoprotein measurements by maintaining reference methods for cholesterol, 
triglyceride, and HDL. In collaboration with the National Heart, Lung, and Blood 
Institute, CDC provides standardization service to 150 domestic and international 
lipid laboratories participating in longitudinal studies and clinical trials involving 
lipid metabolism and the assessment of risk factors associated with coronary heart 
disease. CDC has also established a national reference method laboratory network 
for cholesterol. This network standardizes clinical laboratories and manufacturers of i 
diagnostic products to assist in meeting the Healthy People 2000 objective that a 
least 90% of clinical laboratories measure cholesterol within the recommended na- 
tional standard for accuracy. 

National Center for Health Statistics 
background 

The National Center for Health Statistics (NCHS) is the Federal Government's 
principal health statistics agency. The NCHS data systems address the full spec- 
trum of concerns in the health field from birth to death, including overall health 
status, life style, the onset and diagnosis of illness and disability, and the use of 
health care. 



I 



143 



The Center maintains over a dozen surveys that collect health information 
through personal interviews; physical examination and laboratory testing; review of 
hospital, nursing home, and physician records; and other means. These data sys- 
tems, and the analysis and reports that follow, are designed to provide information 
useful to a variety of policy makers and researchers. NCHS frequently responds to 
requests for special analyses of data that have already been collected and solicits 
broad input from the health community in the design and development of its sur- 
veys. 

Since most of the data systems maintained by NCHS encompass all age groups in 
the population, a broad range of data on the aging of the population and the result- 
ing impact on health status and the use of health care are produced. For example, 
NCHS data have documented the continuing rise in life expectancy and trends in 
mortality that are essential to making population projections. Data are collected on 
the extent and nature of disability and impairment, limitations on functional abili- 
ty, and the use of special aids. Surveys currently examine the use of hospitals, nurs- 
ing homes, physicians' offices, home health care and hospice, and are being expand- 
ed to cover hospital emergency rooms and surgi-centers. 

In addition to NCHS surveys of the overall population that produce information 
about the health of older Americans, a number of activities provide special empha- 
sis on the aging. They are described Jbelow. 

A FOCAL POINT FOR DATA ON AGING 

In 1989, NCHS established a focal point for data on aging by creating a position of 
Coordinator of Data on Aging. Joan F. Van Nostrand is the Coordinator. This focal 
point cuts across the Center's data systems to coordinate: 

— the collection, analysis and dissemination of health data on older Americans 

— international research in data on aging 

— measurement research in aging in such areas as development of a uniform data 
set for long-term care and assessment of disability 

The Coordinator provides information to the general public about NCHS activities 
and data on aging Americans. For more information contact: Joan F. Van Nostrand, 
NCHS Coordinator of Data on Aging, National Center for Health Statistics, 6525 
Belcrest Road, Room 1120, Hyattsville, Maryland 20782. 

INTERNATIONAL COLLABORATIVE EFFORT ON MEASURING THE HEALTH AND HEALTH CARE 

OF THE AGING 

NCHS launched the International Collaborative Effort on Measuring the Health 
and Health Care of the Aging (abbreviated as the ICE on Aging) in 1988. The pur- 
pose of the ICE on Aging is to join with international experts in conducting re- 
search to improve the measurement of health and health care of the aging. Re- 
search results will be applied to the Center's programs to strengthen the collection, 
analyses and dissemination of data on older persons. Results also will be disseminat- 
ed widely to encourage their international application. The international emphasis 
of the research permits the exchange of perspectives, approaches and insights 
among nations facing similar situations and challenges. 

The first International Symposium on Data on Aging was held in late 1988 to de- 
velop proposals for research in selected areas. Proceedings from the 1988 Symposi- 
um were published in 1991 in the Center's "Vital and Health Statistics Series." The 
following research projects began in 1989: 

— Comparative Analysis of Health Statistics for Selected Diseases Common in 
Older Persons — Hip Fracture: USA and Hong Kong. 

— Measuring Outcomes of Nursing Home Care: USA, Australia, Canada, The 
Netherlands, Norway. 

— The Measurement of Vitality in Older Persons: USA, Italy and Israel. 

— Health Promotion and Disease Prevention Among the Aged: USA and the Neth- 
erlands. 

— Functional Disability: USA, Canada, and Hungary. 

A second International Symposium presenting interim results of these research 
projects was held in 1991. Proceedings will be available in early 1993. A third and 
final international symposium is planned for 1994-95 to present final research re- 
sults. 

NCHS has issued several "Information Updates for the ICE on Aging." They de- 
scribed each research project in depth and detail progress. 



144 



FEDERAL INTERAGENCY FORUM ON AGING-RELATED STATISTICS 

The NCHS, in conjunction with the National Institute on Aging and the Bureau 
on the Census, co-chairs the Federal Interagency Forum on Aging-Related Statistics. 
The Forum encourages communication and cooperation among Federal agencies in 
the collection, analysis, and dissemination of data on the older population. The 
Forum membership consists of over twenty Federal agencies that produce or ana- 
lyze data on the aging population. 

Recently, the Forum prepared the following outputs. Copies are available from 
the NCHS Coordinator of Data on Aging: 

— PC lotus disk of tables from "Health Data on Older Americans, United States: 
1992." 

— Pocket edition of "Health Data on Older Americans, United States: 1992." 

— Symposium on health of the elderly at the 1992 annual meeting of the Ameri- 
can Public Health Association and a symposium on the rural elderly at the 1992 
annual meeting of the Gerontological Society of America. 

— Measuring the Activities of Daily Living: Comparison Across National Surveys 
by Wiener, Hanley, Clark and Van Nostrand in "Journal of Gerontology," Vol. 
45, No. 6. 

— Survey Assessment of Cognitive Impairment and Its Impact on Disability: Rec- 
ommendations for Research. 

— Data Resources in Gerontology: A Directory of Selected Information Vendors, 
Databases, and Archives (with the Gerontological Society of America). 

— Directory of Federal Contacts About Older Americans in Rural Areas. 

— Presentation of an informal briefing on older Americans in rural areas to mem- 
bers of Congress and their staff. This was conducted under the auspices of the 
Senate Committee on Aging. 

— Synthetic State Estimates of the Health of Older Persons. 

Forum activities for 1993 include: 

— Publication of a comprehensive analytic report "Health Data on Older Ameri- 
cans, United States: 1992." 

— Publication of "Chartbook on Health Data on Older Americans, United States: 
1992" as a companion to the comprehensive analytic report. 

— Publication of a report "Common Beliefs About The Rural Elderly: What Do 
National Data Tell Us?" 

— Development of a prototype report on "Trends in Health of Older Americans." 

VITAL STATISTICS ON AGING 

Mortality statistics from the national vital statistics system continue to play an 
important role in describing and monitoring the health of the elderly population. 
The data include measures of life expectancy, causes of death, and age-specific 
trends in death rates. The basis of the data is information from death certificates, 
completed by physicians and funeral directors, used in combination with population 
information produced by the U.S. Bureau of the Census. 

At NCHS two efforts are currently underway to both assess and improve mortali- 
ty data for the elderly. NCHS is looking into the possibility of increasing the level of 
age detail shown in tabulations of mortality for the elderly, focussing on the age 
group 85 years and over, which is often treated in tabulations as an aggregated cate- 
gory. As life expectancy has increased, the need for detailed mortality data for the 
"extreme aged" has increased accordingly. Current efforts involve assessing both 
the availability and quality of mortality and population data for more detailed age 
groups among the elderly. 

Also under study is the process by which medical information on the death certifi- 
cate is collected, including issues related to the format of the case-of-death section. 
The format presently in use, prescribed by the World Health Organization, requests 
that the certifying physician report a single causal chain of medical events that led 
to death, initiated by an "underlying" cause of death. The single sequence concept 
presents difficulties in certification for some elderly deaths which may reflect the 
consequences of several concurrent disease processes. These and other issues related 
to certification are now under study. 

National Health Interview Survey (NHIS): Special Topics 

The NHIS continues to collect data on a wide range of special health topics for 
the civilian, noninstitutionalized population, including the aging population. The 
special health topics for 1992 were: 

— AIDS knowledge and attitudes (same sample adult); 



145 



— income and program participation (all family members); 
— cancer epidemiology and cancer screening. 
For 1993 and 1994 the special topic is disability. 

Data collection for an NHIS data year begins in January of that year and ends in 
December. Public-use data tapes are usually available about one year after the end 
of the data collection. 

National Mortality Followback Survey: 1986 and 1993 

The 1986 National Mortality Followback Survey was the first such survey in 18 
years. Already, 43 papers and publications have used the data. The followback 
survey broadens the information available on the characteristics of mortality among 
the population of the United States from the routine vital statistics systems by 
making inquiry of the next of kin of a sample of decedents. Because two-thirds of all 
deaths in the Nation in a year occur at age 65 or older, the 1986 survey focussed on 
the study of health and social care provided to older decedents in the last year of — — 
life. This is a period of great concern for the individual, the family and community 
agencies. It is also a period of heavy care use. Agency program planning and nation- 
al policy development on such issues as hospice care and home care can be enlight- 
ened by the data from the survey. A public use data tape from the next-of-kin ques- 
tionnaire was released in 1988. A second tape, combining data from the next-in-kin 
and hospitals and other health facilities, was available in 1990. Several survey re- 
ports focused on the aging. They were about persons dying of diseases of the heart 
and of cerebrovascular disease. A 1993 National Mortality Survey is currently being 
planned. 

National Health and Nutrition Examination Survey III 

The National Health and Nutrition Examination Survey (NHANES) provides val- 
uable information available through direct physical examinations of a probability 
sample of the population. The third cycle of this survey, NHANES III, went into the 
field in 1988. NHANES III will provide a unique data base for older persons, as a 
number of important methodologic changes have been made in the survey structure. 
There is no upper age limit (previous surveys had an age limit of 74 years), and the 
sample has been selected to include approximately 1,300 persons aged 80 or older. 
The focus of the survey includes many of the major chronic diseases of aging which 
cause morbidity and mortality including cardiovascular disease, osteoarthritis, osteo- 
porosis, pulmonary disease, dental disease and diabetes. 

In addition to the focus on nutrition, information on social, cognitive and physical 
function in incorporated into the survey. Data from home examinations will be 
available for those unable or unwilling to come to the central examination site, the 
Mobile Examination Center. The major activity in 1992 was the fielding of the 
survey. It is anticipated that in 1993 content development for the longitudinal fol- 
lowup will begin, with data collection commencing in FY 1995. 

NHANES I EPIDEMIOLOGIC FOLLOWUP STUDY 

The first National Health and Nutrition Examination Survey (NHANES I) was 
conducted during the period 1971-75. The NHANES I Epidemiologic Followup Study 
(NHEFS) tracks and reinterviews the 14,407 participants who were 25-74 years/ of 
age when first examined in NHANES I. NHEFS was designed to investigate the re- 
lationships between clinical, nutritional, and behavioral factors assessed at baseline 
(NHANES I) and subsequent morbidity, mortality, hospital utilization, as well as 
changes in risk factors, functional limitation and institutionalization. Followups 
were conducted in 1982-84, 1986 (limited to persons age 55 and over at baseline) and 
1987. A fourth wave of data collection is underway (June 1992-May 1993). 

While persons examined in NHANES I were all under age 75 at baseline, by 1987 
more than 3,600 subjects were over 75, providing a valuable study group to examine 
the aging process. Public use data tapes are available from the National Technical 
Information Service for the first three waves of followup. Each set of four tapes con- 
tain information on vital and tracing status, subject and proxy interviews, health 
care facility stays in hospitals and nursing homes, and mortality data from death 
certificates. All NHEFS Public Use Data Tapes can be linked to the NHANES I 
(baseline) Public Use Data Tapes. 

LONGITUDINAL STUDY ON AGING 

The Longitudinal Study on Aging (LSOA) has been a collaborative effort of the 
National Center for Health Statistics and the National Institute of Aging. The base- 



146 



line information for the LSOA came from the Supplement on Aging (SOA), a supple- 
ment to the 1984 National Health Interview Survey (NHIS). 

The SOA included 16,148 persons 55 years of age and over living in the communi- 
ty in 1984. The Supplement obtained information on housing, including barriers and 
ownership; support, including number and proximity of living children and recent 
contacts in the community; retirement, including reasons for retirement and sources 
of retirement income; and measures of disability, including activities of daily living, 
instrumental activities of daily living and ability to perform work-related activities. 

The sample for the LSOA came from the 7,541 persons who were 70 years of age 
and older at the time of the SOA in 1984. The survey was designed to measure 
changes in functional status and living arrangements, including institutionalization. 
Reinterviews were conducted in 1986, 1988 and 1990. The recontacts were primarily 
by telephone using Computed Assisted Telephone Interviewing (CATI); however, 
when the telephone contact was not feasible, a mail questionnaire was sent to the 
sample person. In addition, to the three reinterviews, permission was obtained from 
the sample person or proxy to match their records with other records maintained by 
the Department of Health and Human Services. 

The fourth version of the LSOA public use data tape was released in October 
1991. The information for the Version 4 files was obtained from: 

—1984 NHIS, SOA, and Health Insurance Supplement to the NHIS 

— 1986, 1988, and 1990 telephone interviews with mail follow-up 

—1984-1989 National Death Index (NDI) match 

—1984-1990 Medicare records match 

The public use data tape includes three files — one for persons, one for Medicare 
hospitalizations, and one for other Medicare use. Each file includes the information 
obtained in the previous reinterviews. A diskette containing detailed multiple cause 
of death data for the LSOA sample is available. The diskette complements the Ver- 
sion 4 public use data tape. Future releases of the LSOA public use data tape will 
include information from additional matches to the NDI and Medicare files. 

The LSOA Version 4 public use data tape is available from three sources: the Na- 
tional Technical Information Service (NTIS), The Division of Health Interview Sta- 
tistics, NCHS, and the National Archives of Computerized Data on Aging. The dis- 
kette is available from NTIS. 

National Health Care Survey (NHCS) 

In order to provide more comprehensive data describing the Nation's use of 
health care providers into an integrated family of surveys, collectively called the 
National Health Care Survey (NHCS). The objectives of the NHCS are to provide 
national data describing the utilization of services in ambulatory, hospital and long- 
term care settings; to provide these data on an annual basis using an integrated 
cluster sample design; and to develop the capability of conducting patient follow-up 
studies. 

Currently, the NHCS includes five ongoing national data collection activities: 
— the National Ambulatory Medical Care Survey — visits to non-Federal, office- 
based physicians; 

— the National Home and Hospice Care Survey — patients of hospices and home 
health agencies; 

— the National Hospital Discharge Survey — discharges from non-Federal, short- 
stay hospitals; 

— the National Hospital Ambulatory Medical Care Survey — visits to emergency 

and outpatient departments of non-Federal, short-stay hospitals; 
— the National Health Provider Inventory — a national listing of nursing homes, 

hospices, home health agencies and licensed residential care facilities. 
Details on specific surveys relevant to the elderly are presented below. Plans call 
for the implementation of the National Survey of Ambulatory Surgery and the Na- 
tional Nursing Home Survey in 1994-96. 

National Home and Hospice Care Survey 

The National Home and Hospice Care Survey (NHHCS) is a national probability 
sample survey of home health and hospice care agencies, their patients and staff. 
The 1992 NHHCS, the first of an annual survey, will collect data from a nationally 
representative sample of 1,500 hospices and home health agencies. All agencies pro- 
viding home health and hospice care will be included in the survey without regard 
to licensure or to certification status under Medicare and/or Medicaid. Information 
about the agency will be collected through personal interview with the administra- 
tor. Information will also be collected about a sample of six current patients and six 



147 



discharged patients through personal interview with designated agency staff. Data 
from the NHHCS will allow analysis of the relationships that exist between utiliza- 
tion, services offered, and charges for care, as well as provide national baseline data 
about home health and hospice care agencies, their patients and staff. 

Data from the NHHCS will be analyzed and published in NCHS Advancedata re- 
ports and in Series 13 Vital and Health Statistics. In addition, data will be released 
in the form of public use computer tapes and in the form of special tabulations pre- 
pared for individual requestors. 

National Health Provider Inventory (NHPI) 

NCHS conducted the NHPI, formerly called the National Master Facility Invento- 
ry, in the spring of 1991. This mail survey includes the following categories of 
health care providers: nursing and related care homes, licensed residential care fa- 
cilities, facilities for the mentally retarded, home health agencies, and hospices. 
Data from the 1991 NHPI will be used to provide national statistics on the number, 
type, and geographic distribution of these health providers and to serve as sampling 
frames for future surveys in the Long-Term Care Component of the National Health 
Care Survey. The 1991 NHPI public-use tapes are expected to be released in Decem- 
ber 1992. 

National Nursing Home Survey 

During 1985, NCHS conducted the National Nursing Home Survey (NNHS) to 
provide valuable information about older persons in nursing homes. The NNHS was 
first conducted in 1973-74 and again in 1977. 

Preliminary data from the 1985 survey were published in 1987 and 1988 about 
nursing home characteristics, utilization, discharges and registered nurses. A sum- 
mary report, which integrated final data from the various components of the 
survey, was published in 1989. Also published were analytical reports on: diagnostic 
related groups, utilization, discharges, current residents and mental health status. 
Public-use computer tapes are available through the National Technical Informa- 
tion Service. 

National Nursing Home Survey Followup 

The National Nursing Home Survey Followup (NNHSF) is a longitudinal study 
which follows the cohort of current residents and discharged residents sampled from 
the 1985 NNHS described above. The NNHSF builds on the data collected from the 
1985 NNHS by extending the period of observation by approximately 5 years. Data 
collection has been completed. Wave I was conducted from August through Decem- 
ber 1987, and Wave II was conducted in the fall of 1988. Wave III began in January 
of 1990 and continued through April. The study is a collaborative project between 
NCHS, HHS and the National Institute on Aging (NIA). The followup was funded 
primarily by NIA and was developed and conducted by NCHS. 

The NNHSF interviews were conducted using a computer-assisted telephone 
interview system. Questions concerning vital status, nursing home and hospital uti- 
lization since the last contact, current living arrangements, Medicare number, and 
source of payment were asked. Respondents included subjects, proxies, and staff of 
nursing homes. 

The NNHSF will provide data on the flow of persons in and out of long-term care 
facilities and hospitals. These utilization profiles will also be examined in relation to 
information on the resident, the nursing home and the community. Public-use com- 
puter tapes are available through the National Technical Information Service. 

IMPROVING QUESTIONS ON FUNCTIONAL LIMITATIONS 

The National Laboratory for Collaborative Research in Cognition and Survey 
Measurement of NCHS conducted several cognitive research projects with old (65- 
74), very old (75-84), and oldest (85 + ) respondents. The objectives were to test the 
adequacy and suggest improvements to existing survey questions for collecting infor- 
mation on functional limitations (e.g., limitations on bathing, dressing, transferring), 
life history events (education, employment, residence, onset of health conditions) 
and falls. 

National Center for Infectious Diseases 

Infectious diseases have a disproportionate impact on older Americans. Pneumo- 
nia and influenza remains the sixth leading cause of death in the United States and 



septicemia has risen dramatically during the past three decades to become the 13th 
leading cause of death. Pneumonia and septicemia are also contributing and precipi- ! i 
tating factors in the deaths of many Americans with other illnesses, especially car- 
diovascular diseases, cancer, and diabetes. The morbidity caused by infectious dis- 
eases is a major detriment of quality of life for millions of older Americans. By pre- f\ 
venting and controlling these diseases, we will greatly enhance and extend their 
lives. 

CDC's efforts to prevent and control nosocomial infections in elderly patients have ' 
been through training of infection control practitioners working in nursing homes 
and conducting surveillance on elderly patients in hospitals. Members of the CDC 
staff periodically present lectures on infection control in nursing homes at various | 
conferences to train individuals assigned to infection control to focus on patient care 
areas and procedures that are associated with the highest risk of infection. Through 
the National Nosocomial Infections Surveillance (NNIS) system, the special infec- , 
tion risks of elderly patients have been identified. According to NNIS, over half of L 
the nosocomial infections occur in elderly patients, although these patients repre- jj 
sent only about one-third of all discharges from hospitals. The use of certain devices, \ 
such as urinary catheters, central lines and ventilators, are associated with high i 
risk of infection in all types of patients. In elderly patients, the risk of infection is 
high even when a device is not used, suggesting that infection control must address 
other risk factors in addition to device use, such as poor hygiene and nutrition and 
lack of mobility. 

Although delivering influenza vaccine to persons at risk is a critical step in pre- 
venting morbidity and mortality from influenza, it is only part of the prevention 
equation. CDC's efforts to combat influeza in the elderly include: conducting immun- 
ological studies involving laboratory and clinical evaluation of inactivated and live 
attenuated influenza vaccines in an effort to identify improved vaccine candidates; 
increasing surveillance of influenza in the People's Republic of China and other 
countries in the Pacific Basin to better monitor antigenic changes in the virus; im- 
proving methodologies for rapid viral diagnosis; and using recombinant DNA tech- 
niques to develop influenza vaccines that may protect against a wider spectrum of 
antigenic variants. 

Pneumococcal pneumonia causes an estimated 40,000 deaths each year; 80-90 per- 
cent of these are in persons >65 years old. Prevention of pneumococcal disease in 
the elderly requires widespread application of effective immunization. However, the 
currently formulated vaccine covers only certain serotypes. CDC is working to devel- 
op and promote the widespread use of an improved pneumococcal vaccine with ex- 
panded coverage and enhanced efficacy. This will substantially decrease mortality 
and morbidity from pneumococcal infections in the elderly. Cost-benefit analyses, 
which are favorable for the current vaccine, would be more heavily weighted in 
favor of a more effective vaccine. 

Group B streptococcus (GBS) is a major cause of invasive bacterial disease in el- 
derly persons in the United states. To document the magnitude of GBS disease in 
the elderly and develop preventive measures, CDC established population-based sur- 
veillance for GBS disease and case control studies to identify risk factors for GBS 
disease in the elderly. The impact of preventive measures will be measured through 
surveillance, and an evaluation of potential utility and cost effectiveness of vaccines 
will be performed. The project will result in a prevention program for GBS disease 
which will include evaluation of the role for vaccination based on the risk factor 
study, incidence data, and efficacy trial results. 

Recent studies have suggested that noninfluenza viruses such as respiratory syn- 
cytial virus and the parainfluenza viruses may be responsible for as much as 20% of 
serious lower respiratory tract infections in the elderly. These infections can cause 
outbreaks that may be controlled by infection control measures and be treated with 
antiviral drugs. Consequently, it is important to define the role of these viruses and 
risk factors for these infections among the elderly population. CDC plans to set up 
collaborative studies with State public health departments to do surveillance on out- 
breaks of respiratory illness in nursing homes and assess transmission patterns and 
efficacy of prevention programs. 

Studies using information from national data bases show that of all age groups, 
the elderly (>70 years) have the greatest number of hospitalizations and deaths as- 
sociated with diarrhea in the United States. To evaluate more precisely the public 
health significance and potential prevention and treatment modalities of diarrhea 
in the elderly, the CDC plans to initiate prospective multi-center studies in high risk 
groups such as the elderly in nursing homes and hospitals as well as prospective 
studies on incidence and impact of diarrhea in elderly outpatients. 



149 



Efforts to control this important cause of morbidity will also require further study 
of the agents involved and their transmission. The recent identification of rotavirus 
as a cause of epidemic diarrhea in the elderly suggests that one approach to control 
may involve use of vaccines currently being developed for young children. 

The causes of the steady increase in deaths due to septicemia have not been fully 
explained by existing studies. CDC plans to examine in depth the issues related to 
this rise in septicemia mortality and assess the relative contributions of various po- 
tential risk factors, including changes in population, impact of newer medical thera- 
pies, and other currently undefined factors. Studies of the cost-benefits of prevent- 
ing these infections will also be done. 

National Center for Injury Prevention and Control 

Several CDC-funded Injury Research and Capacity Building Grants have focused 
on injury prevention in the elderly. In September 1989, CDC awarded 15 capacity- 
building grants to state and local health departments. The following capacity-build- 
ing grants have components to assist the elderly: 

Colorado's South West Improvement Council (SWIC), a community-based organiza- 
tion, has developed a fall prevention program for the elderly. The program involves 
volunteer home audits, maintenance and repair. 

In North Carolina, as the objective of the fall prevention program, assessments in 
homes of elderly persons were conducted and home assistive devices were installed. 

In Rhode Island, a program supporting senior centers and community action pro- 
grams was funded to do home assessments, environmental modification and educa- 
tional presentations to high risk groups (i.e., elderly persons already using canes 
and walkers). 

New York State has supported prevention of fall injuries among the elderly in 
two counties. The projects will provide education and safety devices and will include 
an evaluation component. 

In Florida, two counties have selected interventions addressing injuries from falls. 
Both counties will provide education programs and workshops to increase awareness 
about the prevention of falls. 

Research in Washington has found that two- thirds of the falls resulting in hip 
fracture occurred while the elderly person was wearing an unsturdy shoe. The 
Washington State Injury Prevention Program has contracted with the Harborview 
Injury Prevention and Research Center to conduct a pilot project to reduce falls in 
older adults through public education and promotion of safe and sturdy shoes. 

Research grants to study problems affecting the elderly include: 

Determinants of Outcome in Elderly Burn Patients: Investigators will develop a 
system for assessment of thermal injury in patients aged 45 years and older. They 
will examine mortality, morbidity, including complications, rehabilitation status, 
and cost of care. 

Biomechanics of Hip Fractures Risk: The goals of this project are to understand 
the biomechanics of hip fractures among the elderly. CDC-supported researchers are 
investigating the suitability of various materials for hip pads and will construct pro- 
totype pads and initiate a preliminary acceptance and compliance study in nursing 
home and community dwellers. 

Benzodiazepines and Motor Vehicle Crashes in the Elderly: Investigators will 
create a surveillance system in a defined population of persons over 65 years old, so 
that epidemiologic studies of the influence of prescribed medications on the risk of 
motor vehicle crashes can be conducted. 

Preventing Falls in the Nursing Home: This study seeks to evaluate an interven- 
tion to reduce falls among nursing home residents by comparing rates of falls be- 
tween intervention and control nursing homes. The intervention targets environ- 
mental safety, caregiving practices, medications, resident activity, and resident and 
staff education. 

Dually Stiff Floors for Injury Prevention of the Elderly: Investigators are develop- 
ing an intervention to reduce injuries from falls based on dually stiff flooring. This 
project offers the possibility of a significant advance in protection from injuries due 
to falls and the proposed intervention could have wide application in living areas for 
the elderly. 

Spectral Signature as a Predictor of Falls in the Elderly: Researchers will develop 
a method to identify elderly individuals that may be at risk of falling. This method 
will involve the use of the spectral signature of force plate data obtained from pos- 
tural sway to predict the potential of falls among elderly patients. Data from this 
study will augment existing knowledge in the area of biomechanical prevention of 
falls. 



150 

National Center for Prevention Services 
immunization 

CDC is continuing its efforts to increase the awareness of adults to be immunized 
against the vaccine-preventable disease of influenza, pneumococcal disease, hepatitis 
B, measles, mumps, rubella, tetanus, and diphtheria. As a liaison with outside orga- 
nizations that promote adult immunization activities, such as the Administration on 
Aging, the American College of Physicians, and the American Hospital Association, 
CDC provides speakers for conferences and technical review of documents. CDC re- 
sponds to public inquiries and has available a booklet for the lay public, Immuniza- 
tion of Adults: A Call to Action, which promotes immunization of adults in the com- 
munity. CDC is also continuing assistance to State and local health systems in ex- 
panding immunization program coverage of adult populations through promotion of 
the Recommendations of the Advisory Committee on Immunization Practices 
(ACIP). These recommendations were revised and published in November, 1991. 

CDC continues to include adult immunization issues in its annual National Immu- 
nization Conferences. In the 25th Conference held in Washington, D.C. in June 1991, 
there was one poster and two oral presentations concerning adult immunization. In 
the 24th and 26th Conferences held in Orlando, FL in May 1990, and in St Louis, 
MO in June 1992, respectively, at least one poster and eight oral presentations ad- 
dressed various adult immunization issues. The proceedings from the 24th and 25th 
Conferences have been published; those from the 26th Conference will be published 
and distributed in early 1993. 

A 3-year cooperative agreement was completed with a health maintenance organi- 
zation (HMO) trade organization to measure vaccine use and develop procedures to 
increase acceptance of adult vaccines by HMO subscribers. The major accomplish- 
ments under this commitment include: (1) an assessment of HMO policies and prac- 
tices regarding adult immunization; (2) an assessment of vaccine-preventable disease 
morbidity and mortality in five HMOs; (3) aggressive promotion of influenza vaccine 
in the fall of 1989 by the five HMOs; (4) documented reduction of morbidity among 
older persons who received influenza vaccine as compared to unvaccinated persons 
after the vaccine promotion, as well as reduction in medical costs of the vaccinated 
persons; and (5) distribution of a summary report about the agreement to the HMO 
industry, and publication of a synopsis of the report in an HMO trade publication. 

CDC continues to participate in the National Coalition for Adult Immunization 
(NCAI), a network of 63 private, professional, and volunteer organizations, and 
public health agencies with the common goal of improving immunization status of 
adults. Each year during the last week of October, the NCAI promotes National 
Adult Immunization Awareness Week to emphasize the importance of vaccinating 
all adults. To unify the diverse interests of the member organizations and offer a 
foundation of common goals, the NCAI has developed and adopted the Standards for 
Adults Immunization Practice. The standards outline basic strategies that, if fully 
implemented, would improve delivery of vaccines to adults and help achieve the 
Year 2000 National Health Objectives. The objectives of the NCAI are accomplished 
by three working Action Groups — Influenza/Pneumonia, Measles-Mumps-Rubella, 
and Hepatitis B — that conduct disease-specific informational and educational activi- 
ties for health care providers and the public. To combat influenza and pneumococcal 
disease as leading causes of morbidity and mortality for persons over age 64 and to 
increase the number of health care providers who offer these immunizations, the 
Influenza/Pneumonia Action Group has formed eight State and locally based coali- 
tions across the United States. In the first year of the coalitions' activities, they doc- 
umented increases in overall influenza vaccine delivery in five of the eight sites; in 
the three sites with decreases in overall vaccine delivery, public clinic influenza vac- 
cine delivery rose between 9 percent and 15 percent. 

CDC and the Health Care Financing Administration (HCFA) have completed a 
jointly conducted demonstration project to determine the cost-effectiveness for Medi- 
care to cover the use of influenza vaccine. This project involved the administration 
of influenza vaccine to Medicare Part B recipients in 10 sites for cost-effectiveness 
studies, and in an additional 10 statewide sites to assess three levels of vaccine pro- 
motion and the effectiveness of vaccine delivery by simply making it a covered bene- 
fit under Medicare Part B. Vaccine doses delivered in the cost-effectiveness sites ex- 
ceeded 995,000 in 1991-92, up from approximately 786,000 in 1990-91, and reached 
50 percent of the Medicare Part B population in those sites. Almost 1,700,000 doses 
of vaccine were distributed in the 10 statewide sites in 1991-92 reaching 37 percent 
of the Medicare Part B population. The demonstration was completed in September, 
1992 and a final report will be submitted to Congress in September, 1993. If the 



151 



project successfully demonstrates cost-effectiveness, influenza vaccine will become a 
routine covered expense under the Medicare Part B program. 

CDC and the Health Care Financing Administration are also participating in an 
interagency agreement, begun in 1989, to study the effectiveness of pneumococcal 
vaccine in preventing morbidity and mortality among the Medicare Part B benefici- 
aries in Hawaii. Medicare records are being used to: (1) Evaluate the clinical effec- 
tiveness of pneumococcal vaccination in preventing hospitalization and death of 
Medicare beneficiaries; (2) describe medical care utilization patterns of vaccinated 
and unvaccinated persons; (3) evaluate hospital care patterns of vaccinated and un- 
vaccinated persons; and (4) evaluate long-term outcomes of individuals in relation- 
ship to vaccination status. The interagency agreement will be concluded in 1993. 

TUBERCULOSIS 

Tuberculosis (TB) among the elderly is an important problem in that TB cases 
rates among the elderly are higher than in any other age group, during 1991, 6,068 
TB cases were reported among persons 65 and older — the case rate for persons of all 
ages was 10.4 per 100,000 population while the rate for persons age 64 and older was 
19.1. 

Elderly residents of nursing homes are at even higher risk for developing TB than 
elderly persons living in the community. According to a CDC-sponsored survey of 
15,379 reported TB cases in 29 States, the incidence of TB among elderly nursing 
home residents was 39.2 per 100,000 person-years while the incidence of TB among 
elderly persons living in the community was 21.5 per 100,000 person-years. Investi- 
gators have also documented transmission of tuberculosis infection to residents and 
staff in nursing homes during TB outbreaks. 

During 1990, the CDC and the HHS Advisory Council for Elimination of Tubercu- 
losis published recommendations for controlling TB among nursing home residents 
and employees. The recommendations call for TB screening of nursing home resi- 
dents upon admission and employees at entry, annual rescreening for employees, at- 
tention to timely case-finding among symptomatic elderly persons, and the use of 
appropriate precautions to prevent the spread of TB in facilities providing residen- 
tial care for elderly persons. 

ORAL HEALTH AND DENTAL DISEASE PREVENTION 

CDC and the National Institute of Dental Research, NIH, have developed a plan 
to achieve functional and healthy oral conditions for all Americans. The U.S. Public 
Health Service (PHS), through its Oral Health Coordinating Committee, is taking 
steps to implement the PHS Oral Health 2000 Adult Initiative. This initiative, 
viewed as a decade-long commitment, represents the collective effort of PHS agen- 
cies to accelerate improvement in oral health for adult Americans— particularly 
those at increased risk of oral diseases including older adults. The private and vol- 
untary sector will also be involved to facilitate comprehensive approaches to reduce 
the occurrence and severity of oral diseases; prevent the unnecessary loss of teeth in 
the U.S. population; and alleviate physical, cultural, racial/ethnic, social education- 
al, economic, health care delivery, and environmental barriers that prevent adults 
from achieving good oral health. 

Persons are at higher risk for oral cavity and pharyngeal cancer as their age in- 
creases. Approximately 95 percent of oral cavity and pharyngeal cancer occurs in 
persons aged 40 and over, with 60 years as the average age at diagnosis. Individuals 
aged 65 and over experience poorer survival rates from these cancers. 

CDC has developed liaisons with Federal and state agencies to (1) assess the mag- 
nitude of the disease burden from cancers of the oral cavity and pharynx; (2) deter- 
mine the extent of programs currently in place that address the problem; and (3) 
begin development of a comprehensive public health strategy to reduce incidence 
and mortality rates in the United States. CDC and NIH have developed a mono- 
graph on oral cavity and pharyngeal cancers to provide public health, research, edu- 
cation, and health care provider communities with detailed information on the inci- 
dence, mortality, and 5-year relative survival rates for oral and pharyngeal cancer 
in the United States. This publication was published in November 1991. 

A work group composed of representatives from Federal agencies, academic insti- 
tutions, private dentistry, and state health departments was convened by CDC in 
early December to begin developing a national strategy. 

FOOD AND DRUG ADMINISTRATION 

As the percentage of elderly in the Nation's population continues to increase, the 
Food and Drug Administration (FDA) has been giving increasing attention to the 



152 

elderly in the programs developed and implemented by the Agency. To enhance this 
effort, the FDA Working Group on Aging-Related Issues was established in 1992. 
FDA has been focusing on several areas for the elderly that fall under its responsi- 
bility in the regulation of foods, drugs, and medical devices. Efforts in education, 
labeling, drug testing, drug utilization, and adverse reactions have been of primary 
interest. Working relationships exist with the National Institute on Aging, the Cen- 
ters for Disease Control, and the Administration on Aging of the Department of 
Health and Human Services to further strengthen programs that will assist the el- 
derly now and in the future. Some of the major initiatives that are underway are 
described below. 

Patient Education 

To further the goals established by the joint Public Health Service/ Administra- 
tion on Aging Committee on Health Promotion for the elderly, during the last 8 
years FDA has coordinated the development and implementation of significant pa- 
tient education programs with the National Council on Patient Information and 
Education (NCPIE) and many private sector organizations. NCPIE is a nongovern- 
mental group consisting of professional (e.g., medical, pharmacy, nursing), con- 
sumer, and pharmaceutical industry organizations whose goal is to stimulate pa- 
tient education and program development. Special emphasis has been placed on the 
elderly, who use more prescription drugs per capita than the rest of population. 

The "Get the Answers" campaign is a program urging patients to ask their health 
professionals questions about their prescriptions. The major component of the cam- 
paign is a medical data wallet card that lists the five questions patients should ask 
when they get a prescription. These questions are: 

— What is the name of the drug and what is it supposed to do? 

— How and when do I take it — and for how long? 

— What foods, drinks, and other medicines, or activities should I avoid while 

taking this drug? 
— Are there are any side effects, and what do I do if they occur? 
— Is there any written information available about the drug? 

The "Get the Answers" message has been widely disseminated to consumers 
through news releases, advice columns, and other media. Wallet cards with the "Get 
the Answers" message are available through FDA's Office of Consumer Affairs. 

The Women and Medicines Campaign was initiated during "Talk About Prescrip- 
tions" month, October 1991. The purpose of the Campaign is to ensure safer and 
more effective use of medicines through improved communication between women 
and health care providers (e.g., doctors, pharmacists, dentists, nurses). The Cam- 
paign focuses on concerns related to all women, but especially special populations, 
such as the elderly and minorities. It is important because women use more medi- 
cines than men and serve as the medicine managers for other family members. A 
brochure and planning guide were produced by the National Council on Patient In- 
formation and Education with the support and assistance of FDA. These materials 
can be used in many settings, including classrooms, waiting rooms, workplace semi- \ 
nars, and health fairs. 

The brochure "Medicines: What Every Woman Should Know," shares information 
that will assist women to improve communication with health care providers. The 
planning guide, "Women Have Special Medicine Information Needs," shares infor- 
mation that will assist health care providers improve communication with women. 

Concurrent with the activities aimed at patients, FDA, NCPIE and many private 
sector organizations are conducting a major campaign to encourage health profes- 
sionals to provide drug information to their patients. Urging consumers to "Get the 
Answers" and health professionals to "Give the Answers" is vital to bridge the com- . 
munications gap — to get both sides to talk to each other about medications. 

Currently, NCPIE is advocating the use of "Brown Bag Medication Reviews." This 
is a procedure to permit health professionals to review all medication being taken 
by elderly patients. Patients are asked to bring in all their current medication (in a 
brown bag) to an appointment with a physician, nurse, pharmacist, or other health 
professionals. NCPIE is using funds from a grant from the Administration on Aging 
to disseminate materials and promote the program to health professionals. 

FDA's Field Public Affairs Specialists (PAS) have promoted and help conduct 
these brown bag reviews. One of the main target audiences for these reviews is el- 
derly patients. 

In addition to patient education initiatives, FDA and NCPIE are continuing to 
evaluate the effectiveness of patient education programs and are monitoring the at- 
titudes and behavior of consumers and health professionals about patient drug in- 



153 



formation. FDA is encouraged by the number and quality of patient education ac- 
tivities undertaken by the various sectors. FDA will continue to provide leadership 
to foster the patient education initiative. 

FDA's continuing patient education initiatives include the publication of the re- 
print "Testing Drugs in Older People" from the November 1990 "FDA Consumer" 
magazine. This article discusses the physiological changes that occur in aging bodies 
and the need for medication adjustment. 

CLINICAL STUDY GUIDELINES 

In 1989, FDA published the "Guidelines for the Study of Drugs Likely to be Used 
in the Elderly." The guideline provides detailed advice on the study of new drugs in 
older patients. It is intended to encourage routine and thorough evaluation of the 
effects of drugs in elderly populations so that physicians will have sufficient infor- 
mation to use drugs properly in their older patients. The guideline serves as a stim- 
ulus to the development of this information and suggests additional steps to spon- 
sors who are already assessing the effects of their drugs in the elderly. 

PREMARKET TESTING GUIDELINES 

FDA's efforts to ensure that premarket testing adequately considers the needs of 
older people also include educational activities for Institutional Review Boards (IRB) 
through workshops and the dissemination of information sheets on a variety of 
topics of interest to IRBs. An IRB governs the review and conduct of all human re- 
search at a particular institution involving products regulated by FDA. This aspect 
of drug testing and research is particularly important to institutional patients, a 
category comprised of a large number of elderly persons, to ensure adequate protec- 
tion with regard to informed consent. FDA continues to work closely with the Na- 
tional Institutes of Health to develop and distribute information sheets to clinical 
investigators and members of the IRB community. 

Postmarketing Surveillance Epidemiology 

The Office of Epidemiology and Biostatistice prepares an annual report, "Annual 
Adverse Drug Experience (ADE) Report," which analyzes the ADE reports FDA re- 
ceives each year through direct reporting by health professions or through manufac- 
turers' reports. The annual report includes an analysis of ADE reports by age and 
sex that identifies the number of males and females 60 years or older for whom 
ADE reports were submitted. Of 72,749 ADE reports received and computerized in 
1991, 32,654 (61%) reported the age and sex of the patient. Of these reports, 9,741 
(30%) were for individuals 60 years and older. 

Geriatric Labeling 

On November 1, 1990, FDA published a proposed rule to amend its regulations 
pertaining to the content and format of prescription drug product labeling (55 FR 
46134). The proposed rule would require a person marketing a prescription drug to 
collect and disclose available information about the drug's use in the elderly (per- 
sons aged 65 years and over). "Available information" would encompass all informa- 
tion in the applicant's possession that is relevant to an evaluation of the appropri- 
ate geriatric use of the drug, including the results from controlled studies, other 
pertinent pre-marketing or post-marketing studies or experience, or literature enti- 
tled "Geriatric use" with reference, as appropriate, to more detailed discussions in 
other parts of the labeling, such as the "warnings" or "Dosage and Administration" 
sections. The proposed rule is not intended to alter the type of amount of evidence 
necessary to support drug approval but is intended to ensure that special informa- 
tion about the use of drugs in the elderly is well organized, comprehensive, and ac- 
cessible. 

Public comments on this proposed rule were due by December 31, 1990. FDA is 
currently preparing responses to public comments received and anticipates a final 
rule based on the proposal to publish in the "Federal Register" in the spring of 
1992. 

Medication Information Leaflets (MILS) for Seniors 

The American Association of Retired Persons (AARP) Pharmacy Services Divi- 
sion, in conjunction with FDA's Drug Labeling, Research and Education Branch 
(DLREB) publish MILS— educational leaflets about drugs written for use through 
the AARP prescription drug mail order program. In 1989, MILs were written for the 



154 



following classes of drugs: nonsteroidal anti-inflammatory drugs, beta-blockers, beta- 
blocker/thiazide combination drugs, and potassium-sparing diuretics and hydro- 
chlorothiazide combination drugs. Additionally, MILs were revised for several 
agents including: warafrin, belladonna alkaloids and barbiturates, isosorbide dini- 
trate sulfamethoxazole and trimethoprim, quinidine prazosin, cloflbrate sucralfate 
and pentoxifylline. The leaflets provide the patient with: 
— a description of the contents 

— a list of the diseases for which the drug is used as a treatment 

— information the patient should tell the physician before taking the medication 

— dosage information — how the medication should be taken 

— instructions on what to do if a dose is missed 

— possible interactions with other medications 

— possible serious and nonserious side effects 

In 1991, MILs that were revised and updated included: Probenecid, Nitroglycerin, 
and Ranititidine/Famotidine. 

"Marketing Research" Study 

The FDA designed and supervised the data collection of a survey to assess infor- 
mation needs and motivations of subgroups of older individuals with hypertension 
who subscribe to the AARP Pharmacy Service. Analyses identified four distinct sub- 
audiences who are expected to respond differently to varying health promote mes- 
sage strategies. 

An article entitled "A Segmentation Analysis of Prescription Drug Information- 
Seeking Motives Among the Elderly" was published in the "Journal of Public Policy 
and Marketing" (Fall 1992) and was presented at the 1992 Marketing and Public 
Policy Conference in Washington, D.C., May 15-17, 1992. In a second phase to the 
project, targeted medication information messages are being developed and tested 
on identified sub-audiences. 

Year 2000 Health Objectives 

A consortium of over 300 government and private agencies developed a set of 
health objectives for the Nation which is serving as a national framework for health 
agendas in the decade leading up to the year 2000. The overall program is called 
"Healthy People 2000." In the food and drug safety area, FDA has responsibility for 
objective 12.6, which sets as a target to: 

Increase to at least 75 percent of primary-care providers who routinely review 
with their patients aged 65 and older all prescribed and over-the-counter medi- 
cines taken by their patients each time a new medication is prescribed. 

FDA's Marketing Practices and Communications Branch is conducting a study 
that tracks patients' receipt of medication information from doctors and pharma- 
cists over the past 10 years and will also serve as a baseline for programmatic ef- 
forts in patient education for the Healthy People program for the rest of the decade. 

During the coming year, FDA will work with private sector organizations to ad- 
vance medication counseling activities. One particular initiative is working jointly 
with the American Nurses Association on a project related to counseling elderly pa- 
tients taking multiple medications. Plans for developing materials and methods for 
organizing medications taken and developing materials to help patients taking nu- 
merous medications are being developed. 

Pharmacy Initiative 

During the past year, Dr. David Kessler, FDA Commissioner, has personally 
sought to encourage greater pharmacy-based counseling. Through articles in major 
medical ("New England Journal of Medicine") and pharmacy ("American Pharma- 
cist") journals, Dr. Kessler has encouraged the increased role of pharmacists, using 
computers to generate targeted information, to inform patients about the uses, di- 
rections, risks, and benefits of medication. The pharmacy profession has responded 
positively, bringing many examples of their initiatives to FDA's attention. In par- 
ticular, several organizations have informed FDA of the expanded use of "Pharmacy 
Kiosks" to provide patient instructional materials to their customers. 

Health Fraud 

Health fraud — the promotion of false or unproven products or therapies for 
profit — is big business. These fraudulent practices can be serious and often expen- 
sive problems for the elderly. In addition to economic loss, health fraud can also 



155 



pose direct and indirect health hazards to those who are misled by the promise of 
quick and easy cures and unrealistic physical transformations. 

The elderly, more often than the general population, are the victims of fraudulent 
schemes. Almost half of the people over 65 years of age have at least one chronic 
condition such as arthritis, hypertension, or a heart condition. Because of these 
chronic health problems, senior citizens provide promoters a large, vulnerable 
market. 

In order to combat health fraud, FDA uses a combination of enforcement and edu- 
cation. Tn each case, the Agency's decision on appropriate enforcement action is 
based on considerations such as the health hazard potential of the violative product, 
the extent of the product's distribution, the nature of any mislabeling that has oc- 
curred, and the jurisdiction of other agencies. 

FDA has developed a priority system of regulatory action based on three general 
categories of health fraud: direct health hazards, indirect hazards, and economic 
frauds. The Agency regards a direct health hazard to be extremely serious and it 
receives the Agency's highest priority. FDA takes immediate action to remove such 
a product from the market. When the fraud does not pose a direct health hazard, 
the FDA may choose from a number of regulatory options to correct the violation, 
such as a warning letter, a seizure, or an injunction. 

The Agency also uses education and information to alert the public to health 
fraud practices. Both education and enforcement are enhanced by coalition building 
and cooperative efforts between government and private agencies at the national, 
state, and local levels. Also, evaluation efforts help ensure that our enforcement and 
education initiatives are correctly focused. 

The health fraud problem is too big and complex for any one organization to effec- 
tively combat by itself. Therefore, FDA is working closely with many other groups 
to build national and local coalitions to combat health fraud. By sharing and coordi- 
nating resources, the overall impact of our efforts to minimize health fraud will be 
significantly greater. 

FDA and other organizations have worked together to provide consumers with in- 
formation to help avoid health fraud. 

In 1986, FDA worked with the National Association of Consumer Agency Admin- 
istrations (NACAA) to establish the ongoing project called the NACAA Health Prod- 
ucts and Promotions Information Exchange Network. Information from FDA, the 
Federal Trade Commission (FTC), the U.S. Postal Service (USPS), and State and 
local offices is provided to NACAA periodically for inclusion in the Information Ex- 
change Network. This system provides information on health products and promo- 
tions, consumer education materials for use in print and broadcast programs, and 
the names of individuals in each contributing agency to contact for additional infor- 
mation. 

In 1990 and 1991, FDA's Public Affairs Specialists all over the country have car- 
ried out extensive campaigns against health fraud, particularly targeting senior 
groups. These efforts have included radio and television shows and public service 
announcements, talks, and workshops. 

Regional Hispanic Health Fraud Conference 

FDA has made special efforts to target health fraud information to Hispanics, 
particularly the elderly. As a special population, they are particularly at risk be- 
cause of language and cultural considerations that may limit their access to health 
care and information about health fraud. 

The Hispanic Health Fraud Initiative was kicked-off at the model 1989 National 
Health Fraud Conference of San Juan, Puerto Rico. The primary conference goal 
was to provide practical guidance to individuals and organizations in the Common- 
wealth that would enable them to recognize and defend themselves against health 
fraud, quackery, and misinformation. 

FDA has conducted a series of followup regional conferences throughout Puerto 
Rico and the Continental U.S. The series began in Puerto Rico in September 1990 in 
the Carolina Region. In 1991, the series was continued in Caguas, Fajardo, Ceiba, 
and Humacoa. These conferences were cosponsored with the Congress of Workers 
and Consumers of Puerto Rico (COTACO) and the Puerto Rico Department of Con- 
sumer Affairs. The first in the statewide series of conferences was held in FDA's 
Pacific Region (Culver City, CA), on September 13-14, 1990. Two additional state- 
wide conferences are being planned for 1993 in FDA's Southeast Region in Miami, 
FL, and in the Southwest Region in Albuquerque, NM. 



65-505 - 93 - 6 



156 



"Health Is Life" Consumer Education Campaign 

FDA, the Food Marketing Institute (FMI), and the National Urban League (NUL) 
launched a two-phase cooperative consumer health education campaign which is 
culturally specific (language and graphics) and focused to promote healthy lifestyles 
among African Americans. The campaign components include seven nutritional and j 
health promotion posters, health fairs, and workshops. The posters promote good 
health behaviors and are targeted to the following African American audiences: el- 
derly and young males; pregnant women; children 6 to 12 years of age; adolescents \ \ 
12 to 17 years of age; and the general population. Several national organizations ex- 
pressed an interest in the campaign and participated in the orientation and training 

forum National Urban League Affiliates, FDA field Public Affairs Specialists, 

American Dietetics Association, and the Food Marketing Institute. The campaign 
series will be launched in February 1993, and tour six cities: Houston, Texas (Febru- 
ary 20, 1993), New Orleans, Louisiana (February 27, 1993), Tallahassee, Florida 
(March 6, 1993), Winston-Salem, North Carolina (March 13, 1993), Columbia, South ! 
Carolina (March 20, 1993), and Richmond, Virginia (March 27, 1993). 

The campaign was unveiled at the July 1991 annual convention of the National 
Urban League and has been promoted through over 150 other national African 
American multiplier organizations, such as the Auxiliary to the National Medical 
Association; National Council of Negro Women; LINKS, Inc.; Delta Sigma Theta So- 1 
rority; and the Congressional Black Caucus. The NUL's affiliate network of 114 I 
local organizations are displaying and promoting them to their respective constitu- 
encies along with promoting the relationship between diet and health. An additional j 
3,000 copies of the posters were provided to the FMI membership for display in 1 
member food store chains. 

Activities of Public Affairs Specialists 

Mammography, an x-ray examination of the breast used as a screening tool in the 
detection breast cancer, is the best method currently available for detecting tumors 
in their early stages, offering women their best chance for survival. 

To inform women and health care providers about mammography and the early 
detection of breast cancer, FDA's Office of Consumer Affairs (OCA) and the Center 
for Devices and Radiological Health (CDRH) initiated and education campaign focus- j 
ing on the need to select a quality mammography facility. 

In 1990, the OCA and CDRH continued their educational efforts in providing in- 
formation on mammography. A breast cancer and mammography packet was 
mailed to 10,000 consumer organizations and individuals. The packet included mate- i 
rials developed to inform women and health care providers about mammography, a 
"Mammography Screening Update" providing guidelines for the detection of breast j 
cancer in women without symptoms, and a bibliography of publications on breast j 
cancer available from the National Cancer Institute. 

A comprehensive story on hearing aids by a Public Affairs Specialist in an Orlan- 
do, Florida, newspaper elicited over 1,000 requests for information, sparking a na- 
tionwide initiative by FDA field offices to bring more information on these devices 
to the public. 

OCA is working with the Philadelphia and Newark District Offices to pilot a con- 
sumer education program called Pharm- Assist, designed to deliver prescription in- 
formation to elderly, disadvantaged, non-English speaking, and minority consumers. 
Consumer HELP, an independent consumer group, and Ciba-Geigy, a manufacturer, 
are supporting this initiative. 

Food Labeling 

In recognition of the fact that elderly people have a greater need for more infor- 
mation about their food to facilitate preparation for special diets, maintain adequate 
balance of nutrients in the face of reduced caloric intake, and assure adequate levels 
of specific nutrients which are known to be less well absorbed as a result of the 
aging process (e.g., vitamin B12), food labeling is very important to this group. The 
new food label will soon offer more complete, useful and accurate nutrition informa- 
tion to enable the elderly to meet those needs. Significant labeling changes include: 
nutrition labeling for almost all foods; information on the amount per serving of 
saturated fat, cholesterol, dietary fiber, and other nutrients that are of major health 
concern to today's consumers; nutrient reference values that can help consumers to 
see how a food fits into an overall daily diet; uniform definitions for terms that de- 
scribe a food's nutrition content (e.g. "light", "low-fat", and "high-fiber"), particular- 
ly helpful for consumers trying to moderate their intake of calories or fat and other 



157 



nutrients; claims about the relationship between specific nutrients and disease, such 
as sodium and hypertension; standardized serving sizes; declaration of total percent- 
age of juice in juice drinks; and voluntary quantitative nutrition information for 
raw fruit, vegetables, and fish. While manufacturers will have until May 1994 to 
comply with most of the new labeling requirements, regulations pertaining to 
health claims become effective May of 1993. In addition, to help consumers get the 
most from the new food label, educational materials will appear early in 1993. 

TOTAL DIET STUDIES 

The Total Diet Study, as part of FDA's ongoing food surveillance system, provides 
a means of identifying potential public health problems with regard to diet for the 
elderly and other age groups. Through the Total Diet Study, FDA is able to measure 
the levels of pesticide residues, toxic elements, chemicals, and nutritional elements 
in selected foods of the U.S. food supply. In addition, the Study allows FDA to esti- 
mate the levels of these substances in the diets of twelve age groups: infants 6-11 
months; children 2, 6, and 10 years old; 14-16-year-old boys; 14-16-year-old girls; 25- 
30-year-old men; 25-30-year-old women; 40-45-year-old men; 40-45-year-old women; 
60-65-year-old men; 60-65-year-old women; men 70 years and older; and women 70 
years and older. Because of Total Diet Study is conducted yearly, it also allows for 
the determination of trends and changes in the levels of substances in the food 
supply and in daily diets. 

POSTMARKET SURVEILLANCE OF FOOD ADDITIVES 

FDA's Center for Food Safety and Applied Nutrition (CFSAN) monitors com- 
plaints from consumers and health professionals regarding food and color additives, 
dietary supplements, and dietary practices, as part of its Adverse Reaction Monitor- 
ing System. Currently, the database contains approximately 8,500 records. Of the 
complainants who reported their age, approximately 7.5 percent were individuals 
over age 60. 

PROJECT ON CALORIC RESTRICTION 

FDA is participating in research which could lead to significant insight into the 
relationship between dietary habits and lifespan. The Project on Caloric Restriction 
(PCR) is a collaborative effort of FDA's National Center for Toxicological Research 
(NCTR) and the National Institute on Aging (NIA). It is designed to study whether a 
diet that is calorically restricted will add to the longevity and health of laboratory 
rats and mice. An increasing interest in the role of caloric restriction in aging cou- 
pled with the potential economic impact associated with health care was the impe- 
tus for the creation of the PCR. 

The extraordinary interest displayed by research groups across the country and 
the NCTR's commitment to the PCR project has produced a scientific environment 
conducive to the interchange of ideas and the formulation of new approaches to the 
diverse scientific disciplines. NCTR developed a matrix which identifies areas of on- 
going research, identifies additional research areas that need to be addressed and 
helps to avoid duplication of research effort. 

Current study results from NCTR indicate that calorically restricted animals are 
living longer than animals on unrestricted diets and are exhibiting a reduced inci- 
dence of all forms of spontaneous toxicity. In other words, caloric restriction may 
dramatically influence cancer development toxic response, and biological processes 
usually associated with aging in animals. 

Recent investigations in various laboratories agree that dietary caloric restriction 
is effective in extending average and maximum achievable life span in animals and 
in retarding a broad spectrum of age related disease processes, including spontane- 
ously occurring and chemically induced cancers as well as that of many age associ- 
ated noncancerous lesions. 

DNA repair is increased in calorically restricted animals. Hormonal mechanisms 
may be responsible for the relative of in this parameter. Oxidative free-radical 
damage appears to be decreased with caloric restriction in animals and perhaps in 
humans. 

Caloric restriction does not appear to be harmful to behavioral functioning, and 
may be beneficial for some tasks. Effects of restriction on neural cells, especially 
hippocampal cells, need further evaluation. 

Many of these results are consistent with the idea that caloric restriction induces 
an adaptation phenomenon within at least some animal species. Not all functions 
are altered. Rather those processes that appear to be most affected are those which 
have been previously referred to as longevity assurance processes. These processes 



158 



have as their primary role maintenance of the information flow and content of bio- ' 
logical systems and work in concert with one another with the end result being the i 
multiple of these interactive changes. By fine tuning these processes, possibly via j 
altering gene expression in some very basic way, animals may keep themselves alive 
until a more advantageous period for reproduction. By studying mechanisms of j 
action, we can hopefully gain the advantages of this adaptation phenomena without i 
its negative consequences and discomforts. 

The collaborative project between NCTR and NIA is currently undergoing expan- 
sion in order to provide animals to more interested researchers and broaden the in- : 
formation base on biomarkers of aging and mechanisms of aging. 

Intraocular Lenses 

Data on intraocular lenses (IOLs) continue to demonstrate that a high proportion I 
(85-95 percent) of the patients will be able to achieve 20/40 or better vision with the 
implanted lenses and that few (3 to 5 percent) will experience poor visual acuity 
(20/200 or worse). The data also demonstrate that the risks of experiencing a signifi- 
cant post-operative complication are not great. Furthermore many of the complica- 
tions result during the early post-operative period and are associated with cataract 
surgery; the incidence of these complications is generally not affected by IOL im- j 
plantation. Approved lenses have significant impact on the health of elderly pa- } 
tients having surgery to remove cataracts. The IOLs, because they are safe and ef- 
fective, have come the treatment of choice, allowing elderly patients to maintain 
their sight and thus their ability to drive and otherwise lead normal lives. FDA con- i 
tinues to monitor several hundred investigational IOL models and has, to date, ap- | 
proved thousands of models as having demonstrated safety and effectiveness. 

FDA scientists have tested the optical quality of IOLs being marketed. FDA stud- 
ies include measurements of focal length, resolving power, astigmatism, and image 
quality. This information provides a useful data base for making decisions about op- 
tical quality of new IOL designs. Test results show that the overall optical quality of 
currently marketed IOLs is excellent. 

Pacemakers 

Dysfunction of the electrophysiology of the heart can develop with age, be caused 
by disease, or result from surgery. People with this condition can suffer from faint- 
ing, dizziness, lethargy, heart flutter, and a variety of similar discomforts or ills. 
Even more serious life-threatening conditions such as congestive heart failure to fi- 
brillation can occur. 

The modern pacemaker is designed to supply stimulating electrical pulses when 
needed to the upper or lower chambers of the heart or with some newer models, 
both. It has corrected many pathological symptoms for a large number of people. 

Approximately half-a-million elderly persons have pacemakers. An estimated 
125,000 pacemakers are implanted annually, 30 percent being replacements. An esti- , 
mated 75 percent of these are for persons 65 years of age or older. Without pace- 
makers, some of these people would not have survived. Others are protected from 
life-threatening situations and, or most, the quality of life has been improved. 

FDA, in carrying out its responsibilities of ensuring the safety and efficacy of car- 
diac pacemakers, has classified the pacemaker as a Class III medical device. Devices 
in Class III must undergo testing requirements and FDA review before approval is 
granted for marketing. 

In addition, FDA in conjunction with the Health Care Financing Administration 
(HCFA) of the Department of Health and Human Services has instituted a national i 
registry of cardiac pacemaker devices and leads. HCFA and FDA have developed an 
operational registry with a data base of approximately 870,000 pacemaker and lead 
entries to date. 

Physicians and providers of health care services must submit information to a na- 
tional cardiac pacemaker registry if they request Medicare payment for implanting, 
removing, or replacing permanent pacemakers and pacemaker leads. The final rule 
implementing the national registry was published by FDA and HCFA in the July 
23, 1987, "Federal Register" and became effective on September 21, 1987. 

Under this new rule, physicians and providers of services must supply specified j 
information for the pacemaker registry each time they implant, remove or replace a 
pacemaker or pacemaker lead in a Medicare patient; HCFA may deny Medicare 
payment to those who fail to submit the required data. The information is submit- 
ted to HCFA's fiscal intermediaries at the same time as the bill for services and 
HCFA relays the data to FDA. Health care providers may obtain forms for submit- 
ting the information from the fiscal intermediaries. 



159 

The required information includes: 

The name of the manufacturer, the model and serial number of the pacemak- 
er or pacemaker lead, and the warranty expiration date. 

The patient's name and health insurance claim number, the provider 
number, and the date of the procedure. 

The names and identification numbers of the physicians ordering and per- 
forming the surgery. 

When a pacemaker or lead is removed or replaced, the physician or provider must 
also submit the date of initial implantation (if known) and indicate whether the 
device that was replaced was left in the body, and, if not, whether the device was 
returned to the manufacturer. 

Renal Dialysis 

End Stage Renal Disease (ESRD) patients are dependent upon some form of dialy- 
sis treatment, either hemodialysis or peritoneal dialysis, for survival until they re- 
ceive a transplant, or if that is not possible, for the remainder of their lives. More- 
over, ESRD is a disease frequently seen in the elderly. Recent data released by the 
U.S. Renal Data System indicated that the median age adjusted for age and sex for 
new ESRD patients in 1984 was 60 with nearly 40 percent over 64. The incidence 
rates of ESRD vary dramatically among age groups, ranging from 1 in 91,000 below 
age 20, to 1 in 1,876 between ages 64 and 74. 

Because of the nature of the treatment, ESRD patients are vulnerable to a 
number of possible hazards during dialysis treatments. Many of the hazards arise 
from failure to properly maintain and use the equipment, or from insufficient atten- 
tion to the safety features of the dialysis system components. Educational video 
tapes have been provided to the dialysis community to alleviate many of these prob- 
lems. 

Following an educational video on human factors in hemodialysis? FDA in con- 
junction with other organizations, such as the Health Industry Manufacturers Asso- 
ciation (HIMA), the Renal Physicians Association (RPA), and the American Ne- 
phrology Nurses Association (ANNA), have been active in developing several addi- 
tional videos including water treatment, infection control and reuse, and manuals 
on water treatment and quality assurance. Complimentary videos illustrating con- 
cerns and proper techniques have been distributed to every ESRD facility in the 
United States. These videos have received a very high level of acceptance from the 
nephrology community. 

The video on the proper reuse of dialyzers developed by the FDA, RPA, and other 
concerned groups was released. The video follows the protocols detailed in the Asso- 
ciation for the Advancement of Medical Instrumentation (AAMI) Recommended 
Practice for the Reuse of Hemodialyzers. This practice has been adopted by the 
Health Care Financing Administration as a condition of coverage to ESRD providers 
that practice reuse. 

A multi-State study conducted for the FDA in 1987 indicated that dialysis facili- 
ties appeared to be deficient in quality assurance (QA) techniques used in all areas 
of dialysis treatment. To address this problem, FDA funded a contract for develop- 
ment of guidelines that can be used by dialysis facility personnel in establishing QA 
programs. The guidelines printed in February 1991 were mailed to every dialysis fa- 
cility in the United States area free of charge. 

In the past year, FDA has continued to work cooperatively with the nephrology 
community and ESRD patients groups to improve the quality of dialysis treatment. 
These efforts are yielding positive results. 

Mammography 

Since 1975, FDA's Center for Devices and Radiological Health (CDRH) (formerly 
the Bureau of Radiological Health) had conducted a great many mammography ac- 
tivities. These have been done with several goals in mind: 

Reduce unnecessary radiation exposure of patients during mammography to 
reduce the risk that the examination itself might induce breast cancer; 

Improve the image quality of mammography so that early tiny carcinoma le- 
sions can be detected at the state when breast cancer is most treatable with the 
less disfiguring and more successful treatments; 

Improve the ability of radiologists to read and interpret mammograms more 
accurately; and 

Develop an integrated U.S. system of diagnosis and treatment of breast 
cancer, the risk of which increases significantly as a woman ages. 



160 

These activities have been conducted with extensive cooperative involvement with 
all 50 State Radiation Control Programs, with the American College of Radiology, 
with other key health professional organizations, with Federal agencies such as the 
Centers for Disease Control and the National Cancer Institute, as well as with sev- 
eral FDA components. 

Radiological Health Sciences Learning File 

One area of concern was with the accuracy of interpretation of mammograms, pri- 
marily because the radiology residency training programs in previous terms did not 
stress mammography. Consequently, in the early 1980's BRH decided to help im- i 
prove radiology training by adding a Mammography Section to the Radiological 
Health Sciences Learning File. The File is now used in essentially all U.S. medical 
schools and radiology residency programs, as well as many others worldwide. Its 
films form the basis for the American Board of Radiology's credentialing examina- 
tion. 

The Medicare Screening Mammography Benefit 

As the value of mammography became increasingly recognized, concern grew 
about the access of poorer women to this examination. To help solve this problem, 
the Omnibus Reconciliation Act of 1990 provided for the inclusion of screening 
mammography among the benefits of Medicare. This Act also required that provid- 
ers of this benefit meet quality standards for their equipment, personnel, and qual- 
ity assurance programs. CDRH staff were heavily involved in assisting the Health 
Care Financing Administration in developing these quality standards, which were 
published as "interimfinal regulations" on December 31, 1990. By September 8, 
1992, over 6,500 facilities had been certified by HCFA as eligible for reimbursement 
for screening mammography examinations provided to Medicare eligible women. 
The certification was initially based on the facility "self-attesting" that it was in 
compliance with the quality standards. Now HCFA has developed an inspection pro- 
gram that will be the basis for certification in the future. CDRH staff provided tech- 
nical assistance in the development of this inspection program and in the training 
of the inspectors. 

The National Strategic Plan for the Early Detection and Control of Breast 

and Cervical Cancer 

FDA, the National Cancer Institute, and the Centers for Disease Control have co- 
ordinated a combined effort to cover 75 professional, citizen, and government groups 
to develop the National Strategic Plan for the Early Detection and Control of Breast 
and Cervical Cancer. The goal of this plan, approved by the Secretary of Health and 
Human Services on October 15, 1992, is to mount a unified effort by all interested 
groups to combat these two serious cancer threats. FDA staff took the lead in writ- 
ing the Breast Cancer Quality Assurance section, one of six components of the plan, 
and anticipated in the development of the other components. 

Mammography Quality Standards Act of 1992 

On October 27, 1992, the President signed into law the Mammography Quality 
Standards Act of 1992. This Act requires the Secretary of Health and Human Serv- 
ices to develop and enforce quality standards for all mammography of the breast, no 
matter what the purpose or source of reimbursement. By October 1, 1994, any facili- 
ty wishing to produce, develop, or interpret mammograms will have to meet these 
standards to remain in operation. Although responsibility for this Act has yet to be 
assigned to a specific agency, FDA expects to be involved in its implementation in 
some fashion. 

Blood Glucose Monitors 

Recent publications estimate the number of diagnosed diabetics in the United 
States to be 5 million and increasing at a rate of 600,000 per year. Over 65 percent 
of diabetics are 55 years and, of course, many must monitor their blood glucose. 

Since the implementation of Medical Device Reporting (MDR) regulations in De- 
cember 1984, approximately 3,500 reports were submitted to FDA regarding errone- 
ous test results encountered by users of self-monitoring blood glucose (SMBG) sys- 
tems. As a result of these findings, a project was initiated to study and provide solu- 
tions to the problems with use of these devices. The study was conducted in four 
phases: (1) information/data analysis including labeling, instructional and training 



161 



materials; (2) identification of problems and contributing factors, including the use 
of data obtained by survey, contract, scientific literature, laboratory testing and 
MDR submissions; (3) development of a strategy for corrective action(s); and (4) im- 
plementation of corrective actions that could include assistance and collaboration 
with interested organizations. 

As the limitations of the elderly, e.g., slowed response time are deficient vision, 
are important considerations in properly using glucose meters, FDA conducted a 
human factors analysis of blood glucose meters. Completed in May 1990, the goals of 
the analysis were: 

Determine if operation and instructional materials of blood glucose meters is 
compatible with users' ability; 

Determine if the features of blood glucose meters contribute to user error; 
and 

Determine the quality and quantity of instructional material available to 
meter users for learning proper meter operation. 

The study found that instructional materials did not adequately prepare users to 
obtain accurate results. In addition, the study pointed out the need for proper train- 
ing of users by health professionals. It also led to suggestions for design changes to 
enhance the user's ability to obtain accurate readings. 

A National Steering Committee for Quality Assurance Glucose monitoring was re- 
cently formed to address findings of the human factor study. During FY 1993, the 
Committee initiated development of user education strategies and instructional ma- 
terial designed to reduce problems associated with the use of blood glucose meters. 

A consumer brochure containing tips for safe and accurate self-testing of blood 
glucose will be completed in FY 1993. Also, procedural checklists for both the dia- 
betic and the diabetic health care trainer will be completed in FY 1993. 

Patient Restraints 

Soft patient restraints are devices used to protect patients from falls and other 
injuries. Restraints are used mostly on elderly patients. FDA's Medical Device Re- 
porting (MDR) database has documented 60 deaths related to patient restraint use. 
The scientific literature suggests that the annual deaths related to use of this device 
may be as high as 200. Moreover, the use of patient restraints is expected to in- 
crease as the number of elderly persons increases. FDA believes that the users of 
these devices, including doctors, nurses, nursing assistants, and nurses aides need 
better instructional materials to be able to use these devices properly. Accordingly, 
FDA initiated an educational campaign aimed at development of: 

— graphic messages to be used on the restraints and in the package labeling to 
effectively convey important safety information to restraint users; 

— a poster to serve as a reminder about crucial information needed to apply re- 
straints properly; 

— a brochure and exhibit for use at professional meetings; and 

— a learning package to assist facilities in meeting on-going educational needs. 

FDA has also taken steps to label the devices for "prescription use" by health 
care providers, and to change regulations so that FDA can review the devices for 
safety, labeling, and design prior to marketing. 

Vaccines 

The use of pneumococcal vaccine and influenza vaccine in this population has the 
potential for saving many lives annually. Elderly persons are at increased risk for 
complications with influenza infection. Therefore, they are in target groups for spe- 
cial vaccination programs. Scientists at the Center for Biologies Evaluation and Re- 
search (CBER) and other staff work with CDC and WHO collaborating laboratories 
to assure that the vaccine available each year contains strains that would be the 
most effective for the epidemic year. CBER, along with its Vaccine and Related 
Products Advisory Committee makes the final selection after consultation and pro- 
vides appropriate reference materials. 

One of the objectives of Healthy People 2000 of deaths due to epidemic related 
pneumococcal and influenza in part by immunization. In addition, another objective 
of this PHS goal is to reduce pneumonia-related days of restricted activity. Scien- 
tists at CBER perform lot release on both influenza and pneumococcal vaccines 
which may help in this objective. CBER is working in programs directed at improv- 
ing pneumococcal vaccines as well as other vaccines that may be useful in prevent- 
ing infectious diseases in the elderly. CBER evaluates many other biological prod- 
ucts of specific need to the elderly, including diagnostic skin tests for TB and blood 
products. 



162 



Immune Senescence 

Elderly individuals are especially vulnerable, as evidenced by increased morbidity 
and mortality, to a wide spectrum of infectious diseases caused by bacterial and 
viral etiologic agents. Moreover, the incidence of most malignancies increases and 
peaks among the elderly. The immune system is responsible for protection against 
infections, and its proper function is also thought to be instrumental for protection 
against the outgrowth of malignant cells. It is now well documented that advancing 
age compromises the ability of the immune system to fulfill its function. The de- 
creased vigor of the immune response with age is believed to be, at least in large 
part, responsible for the increased vulnerability of the aged to infectious and malig- 
nant diseases. 

Efforts are underway, by investigators at the FDA Center for Biologies Evaluation 
and Research to understand and dissect mechanisms underlying the immunologic 
decline with age. Investigators at CBER, working in collaboration with investigators 
in Japan, are trying to understand why the activity of T cells are decreased with 
age. Proper function of T cells, central players in the immune system, is especially 
crucial to fending off infection and rejecting tumors. Investigators at CBER have 
demonstrated that the expression of certain proteins, and the genes which encode 
them, is reduced with advanced age. These proteins, known as perforin (or pore- 
forming protein or cytolysin) and granzymes, are found within granules in killer T 
cell. They are released upon contact foreign cells (e.g., tumor cells) or virally infect- 
ed cells, and are believed to be involved in the lysis and death of the target cells. 
Moreover, the function of another class of T cell, the helper T cell, is also compro- 
mised with age, and compromise of its function may further magnify the decremen- 
tal function of killer T cells. Investigators at CBER, using a rodent model, have 
shown that these cells exhibit reduced activity within the whole aged animal. One 
ultimate aim of these studies is to determine whether cytokines or biologic agents 
can be used specifically to restore the decreased function of the aged immune 
system to more youthful levels. 

Dialogue With Alzheimer's Organizations 

On September 9, 1992, individuals from several organizations representing Alzhei- 
mer's patients and their families met with the Commissioner to begin a dialogue 
aimed at better understanding the needs and concerns of these organizations and 
their constituencies. The Commissioner emphasized that there are no distinctions 
made by FDA in dealing with issues and products related to life-threatening illness- 
es, and that the Agency is in the process of establishing mechanisms to ensure this 
equality. Increased outreach and a focal point of access for constituencies concerned 
with Alzheimer's, AIDS, and cancer are planned. This meeting was the first in a 
series designed to actively engage the Alzheimer's community in constructive dia- 
logue on their needs and the Agency's role and responsibilities as it impacts those 
needs. 

Specific concerns addressed included: 
— removing import alert on THA 
— obtaining access to study protocols 

— reaching a better understanding of the FDA process for making therapies for 

Alzheimer's available 
— addressing the perception that standards for drug approval differ between AIDS 

and Alzheimer's drugs 
— need to expedite review of Alzheimer's drugs 

Attendees included representatives from the Families for Alzheimer's Rights As- 
sociation, the Alzheimer's Disease and Related Disorders Association, the Alzhei- 
mer's Disease Alliance, and the American Health Assistance Foundation. The con- 
sumer representative on the Peripheral and Central Nervous System Drugs Adviso- 
ry Committee also participated. Agency management expressed their desire to 
expand involvement to other interested groups and organizations who may bring 
different concerns to future meetings. Such meetings will likely address in greater 
detail the Agency's policies, processes, and activities specifically related to Alzhei- 
mer's disease, as well as provide information to patients and families about how to 
enroll in clinical trials. 

HEALTH RESOURCES AND SERVICES ADMINISTRATION 

The Health Resources and Services Administration (HRSA) has lead responsibility 
for Federal efforts to promote access to health care services, primarily through pro- 
grams which increase the availability of community health resources. 



163 

HRSA's programs are far-reaching in their support of health services to disadvan- 
taged and underserved groups. In addition to older people, our clients include moth- 
ers and children, minorities, the homeless, the poor, drug users, migrant workers, 
people with AIDS/HIV, those with Hansen's Disease, and those who need organ 
transplants. Our challenge is to help assure the best possible Care to as many indi- 
viduals as possible at reasonable cost. 

HRSA also provides technical assistance and resources to improve the education, 
supply, distribution and quality of the Nation's health professionals, and access to 
health services and facilities. Our partners in these efforts include State and local 
health departments, universities, private nonprofit organizations, and many other 
participants in the Nation's public health care system. 

A primary emphasis during the past year has been on strengthening the role of 
State and local health departments. HRSA, in conjunction with the Centers for Dis- 
ease Control, has been instrumental in assisting the three organizations represent- 
ing public health officials, the Association of State and Territorial Health Officials 
(ASTHO), the National Association of County Health Officials (NACHO), and the 
U.S. Conference of Local Health Officers (USCLHO), in forming a coordinated ap- 
proach to public health practice with the creation of the Joint Council of Official 
Public Health Agencies. They are currently working on the development of a strate- 
gic plan. 

HRSA is concerned about training our Nation's professionals to provide care for 
today's older individuals and individuals who will be old in the future. The Agency 
provides services to underserved older Americans, such as those who live in rural 
areas and those with low incomes. One quarter of older Americans live in rural 
areas. One out of four elderly Americans, or 7.4 million, are poor or near poor. 

Several HRSA components significantly influence programs and activities that 
benefit older Americans. 

Bureau of Primary Health Care 

The Bureau of Primary Health Care (BPHC) helps assure that primary health 
care services are provided to persons living in medically underserved areas and to 
persons with special health care needs. It also assists States and communities in ar- 
ranging for the placement of health professionals to provide care in health profes- 
sional shortage areas. The Bureau provides services to older Americans through 
Community and Migrant Health Centers (C/MHCs), the National Health Service 
Corps, the Division of Federal Occupational Health, the Home Health Demonstra- 
tion Program, and the Alzheimer's Demonstration Grant Program. 

COMMUNITY AND MIGRANT HEALTH CENTERS 

During fiscal year 1992, C/MHCs, located in medically underserved areas, provid- 
ed a range of family-oriented, preventive, primary health managed care services to 
those who would otherwise lack access to care, particularly the poor and minorities. 
Approximately 6.1 million people were served, of which approximately 8 percent (or 
about 477,000) were age 65 or older. 

The Bureau has entered into collaborative relationships with other organizations 
to better assist C/MHCs in addressing the specific needs, behavior patterns, and 
health concerns of the elderly through planning and evaluation initiatives. One 
such collaborative effort is between the Health Resources and Services Administra- 
tion and the Administration on Aging. Together they provided training to Area 
Agencies on Aging and State Primary Care Association staff to assist them in devel- 
oping statewide plans for health services to the elderly. 

An evaluation of the activities under this collaborative program showed that fi- 
nancial barriers are a major impediment to increasing elderly participation in C/ 
MHCs. In response to this finding, the "Guidebook on Geriatric Program Develop- 
ment in Community and Migrant Health Centers" was developed and distributed to 
C/MHCs. 

THE NATIONAL HEALTH SERVICE CORPS 

The National Health Service Corps places physicians, nurse practitioners, physi- 
cian assistants, certified nurse midwives, and other health professionals in health 
personnel designated shortage areas. Older Americans with special health needs 
and reduced mortality need primary care providers close at hand. The Corps works 
closely with C/MCHs, other primary care delivery systems and the Indian Health 
Service to provide assistance in recruiting and retaining health personnel for popu- 
lations in need. 



164 



DIVISION OF FEDERAL OCCUPATIONAL HEALTH 

The Division of Federal Occupational Health (DFOH) provides a variety of serv- , 

ices related to health promotion and disease prevention in the elderly to managers l 

and employees of over 3,000 Federal agencies. Retirement planning, care of aging c 

parents, and prevention of osteoporosis are some examples of geriatric issues that f 

are regularly addressed in educational seminars and counseling sessions provided by j 
the Division's clinical and employee assistance programs. 

HEALTH CARE SERVICES IN THE HOME DEMONSTRATION PROGRAM 

The Health Care Services in the Home Demonstration Program was developed to j 
identify low-income persons who can avoid unnecessary institutionalization or hospi- 
talization if case-managed skilled home health services are provided in the home. 
Through the program, these services are provided to technology-dependent children, 
disabled adults, the frail elderly, and others who are uninsured or underinsured. 

Five State health departments have been awarded demonstration grants — Hawaii, ! 
Mississippi, North Carolina, South Carolina, and Utah. There were significant vari- j 
ations in terms of demographics, service needs, health resources available, cultural 
attitudes, and State governments among the States. Each State found people who 
were uninsured or underinsured for case managed skilled home health services pro- 
vided by a multidisciplinary team. Many people were inadequately served both in 
terms of their needs, preferences, and quality of care by current services. Together 
these States have provided services to approximately 2,000 uninsured or underin- 
sured clients in the first 4 years of the program. 

It took some time and a re-orientation of thinking for providers both within the ' 
grantee and community to think beyond currently reimbursable services. The usual 
response was to tailor services to what was reimbursable and available rather than 
what the client really needed. It also meant creatively thinking beyond hospitaliza- j 
tion and institutionalization as solutions. 

The multidisciplinary team includes nurses and social workers in all States. 
States were encouraged to include physicians and pharmacists as regular members 
of the team. States have varied in their abilities to do this, e.g., Mississippi, and 
South Carolina being strong in physician involvement, and North Carolina, South 
Carolina and Utah having significant, pharmacist involvement. In all cases in which 
the physician and/or pharmacist — have had a strong role, there have been signifi- 
cant improvements in patient care. The contribution of the pharmacist, as a regular 
member of the multidisciplinary team has increased compliance, reduced side ef- 
fects, and reduced the costs of drugs. Other members have included nutritionists, 
physical therapists, occupational therapists, speech therapists, etc., as needed and 
available. 

Clients and their caretakers have been overwhelmingly pleased with the program. 

The 6-year demonstration includes separately funded evaluation components that 
are studying policy, program, financial, and case management issues addressed by ' 
the five States. Because of their differences in structure, target groups, and clients 
served, it was determined that these projects have unique information relevant to | 
long-term policy discussions, particularly in regard to case management of special j 
populations. The Bureau of Primary Health Care entered into a contract to gather 
and analyze relevant information regarding case-managed skilled home health care 
for special populations. 

In addition, States are doing evaluations at the State level, e.g., a study of care- 
givers in Hawaii; pharmacy use in home health clients in North Carolina; a compar- 
ison study of case-managed versus regular skilled home health care in South Caroli- j 
na; and release of technology dependent children from nursing homes in Utah. 

Approximately $15.5 million has been awarded for this 6-year program. The first 
grants were awarded in Fiscal Year 1988; the demonstration will continue through 
Fiseal Year 1994. 

Alzheimer's demonstration grant program 

The Alzheimer's Demonstration Grant Program was established under Sections 
398, 399, and 399A of the Public Health Service (PHS) Act as amended by Public 
Law 101-557, the Home Health Care and Alzheimer's Disease Amendments of 1990. i 
The first grants, of approximately $3.9 million, were awarded in fiscal year 1992 to 
governmental agencies located in nine States, the District of Columbia, and Puerto 
Rico. It is anticipated that up to 4 new grantees will be funded in FY 1993. 

This demonstration program is designed to demonstrate how existing public and 
private nonprofit resources within a State may be more effectively identified, uti- 
lized, and coordinated to deliver appropriate respite care and supportive services to 



165 



underserved persons with Alzheimer's Disease or related dementias, to their fami- 
lies and caregivers. The program will also identify gaps in the services existing 
within the community and, where possible, develop creative and innovative ap- 
proaches to bridge these gaps. Lastly, the program will identify and develop strate- 
gies to overcome barriers that exist in accessing these services. 

An evaluation strategy, which will include a data collection system, is currently 
being designed so that the effectiveness of the demonstration program can be meas- 
ured at its conclusion. 

Office of Rural Health Policy 

The Office of Rural Health Policy (ORHP) serves as the focal point within the De- 
partment for coordinating nationwide efforts to strengthen and improve the deliv- 
ery of health services to populations in rural areas. In particular, the Office advises 
the Secretary on the effects that the Medicare and Medicaid programs have on 
access to health care by rural populations, especially with regard to financial viabil- 
ity of small rural hospitals and the recruitment and retention of health profession- 
als; coordinates rural health activities within the Department and with other Feder- 
al agencies, States, national organizations, private associations and foundations; ad- 
ministers a national grant program that establishes rural health research centers; 
provides staff assistance to the National Advisory Committee on Rural Health; and 
ensures that the Department invests adequate resources into research projects on 
rural health issues. 

Aging related issues are of particular importance to the Office of Rural Health 
Policy. One quarter of the Nation's elderly live in rural areas and rural counties 
have, on the average, a higher percentage of their population over 65 years of age 
than their urban counterparts. 
Activities and initiatives of the ORHP which affect the rural elderly include: 

Providing an impact analysis to the Health Care Financing Administration 
on proposed and final regulations which are expected to have a significant 
impact on small rural hospitals and the rural elderly that they serve; 

Supporting new and innovative local efforts to extend health care access to 
the rural elderly through a $24.8 million Outreach Grant Program. The pro- 
gram targets elderly and others whose needs have heretofore gone unmet under 
existing Federal programs; 

Coordinating activities with the Bureau of Health Professions and the Bureau 
of Health Care Delivery and Assistance relating to the development and utiliza- 
tion of rural health professionals; 

Meeting with personnel in other Federal agencies (e.g., the Alcohol, Drug 
Abuse and Mental Health Administration and the National Institute on Aging) 
to work on issues which affect the health and health care access of rural elder- 
ly; and 

Apprising interest groups, such as the National Council on Aging and the 
American Association on Retired Persons about ORHP and its activities 

The Subcommittee on Health Services of the National Advisory Committee on 
Rural Health designated the needs of the rural elderly as one of three priority 
areas. Based on the work of the Subcommittee, the full Committee's 1991 report ad- 
dressed a number of problems which rural elders experience in obtaining needed 
health services. The Committee proposed policy actions and programs to improve 
the availability of in-home services, community-based services, health promotion 
programs and transportation services, the adequacy of Medicare reimbursement for 
home health services, and the quality assurance of home health and institutional 
long-term care services. Also, the Committee recommended the issuance of specific 
regulations to implement the Medicare "social factors" provision contained in 
OBRA 1987. The provision directs Medicare's Peer Review Organizations to recog- 
nize "social factors" such as the distance from the patient's home to post-treatment 
care for complications as grounds for approving inpatient hospitalization for some 
treatment that would otherwise be on an outpatient basis. 

Since 1989, the Office has awarded grants to seven rural health research centers 
to conduct applied research, case studies and analyses focusing on the delivery, fi- 
nancing, organization, and management of rural health and care services. The Cen- 
ters provide data and policy research capabilities on a wide range of rural health 
concerns, including areas relevant to the elderly. 

The office also awarded grants to 42 State Offices of Rural Health to help them 
meet the needs of rural communities and the elderly. 

To enhance the dissemination of information on rural health, an interagency 
agreement with the U.S. Department of Agriculture (USDA) was signed in January 



166 



1990. It provides for the placement of the Rural Information Center in, the USDA's 
National Agricultural Library. This Rural Information Center Health Service 
(RICHS), as it is called, commenced operations on October 1, 1990. For access to the 
center, call 1-800-663-7701. 

Bureau of Health Professions 

The Bureau of Health Professions (BHPr) monitors and guides the development of 
health resources by providing leadership to improve the education, training, distri- 
bution, utilization, supply, and quality of the Nation's health personnel. 

The Bureau has established Seven Strategic Directions to achieve the Depart- 
ment's Year 2000 National Health Promotion and Disease Prevention Objectives \ 
and to guide the implementation of the Bureau's programs in an era of health care 
reform. 

The Seven Directions are: 

1. Health Care Reform: Promoting Primary Health Care Education; 

2. Health Care Reform: Increasing the Number of Health Care Providers from Mi- 
nority /Disadvantaged Backgrounds; 

3. Health Care Reform: Establishing Linkages Between Education Programs and 
Service Settings; 

4. Health Care Reform: Assuring Health Care Quality Through Publicly-Respon- 
sive Reforms in Health Professions Education Practice and Liability Management; 

5. Health Care Reform: Strengthening Public Health Education and Practice; 

6. Health Care Reform: Strengthening Health Professions Data, Information Sys- 
tems, and Research; and 

7. Health Care Reform: Building the Capacity of Nursing and Allied Health Pro- 
fessions to Meet the Demands for Health Services. 

The strategy defined by these seven directions will be implemented through a va- 
riety of collaborative public and private efforts and programs supported and operat- 
ed by the Bureau. Programs include: education and training grant programs for in- 
stitutions such as health professions schools and health professions education and 
training centers; loan and scholarship programs for individuals, particularly those 
from disadvantaged backgrounds; the National Practitioner Data Bank; and the 
Vaccine Injury Compensation Program. 

The Bureau supports the Council on Graduate Medical Education. The Council re- 
ports to the Secretary and the Congress on matters related to graduate medical edu- 
cation, including the supply and distribution of physicians, shortages or excesses in 
medical and surgical specialties and subspecialties, foreign medical graduates, fi- 
nancing medical educational programs, and changes in types of programs. It also 
supports the National Advisory Council on Nurse Education and Practice which ad- 
vises the Secretary on PHS Title VII nursing authorities. The Bureau is in the proc- 
ess of establishing the National Commission on Allied Health and the Advisory 
Council on Medical Licensure. 

BHPr administers several education-service network multidisciplinary and inter- 
disciplinary programs such as the Area Health Education Centers, the Geriatric 
Education Centers, and Rural Interdisciplinary Training Programs. In addition, it 
also administers the AIDS Regional Education and Training Centers Program which 
provides multidisciplinary training for primary health care providers in the care of 
HIV-infected individuals and people with AIDS. 

The National Vaccine Injury Compensation Program is administered by BHPr. 
The program, which became effective October 1, 1988, was created by the National 
Childhood Vaccine Injury Compensation Act of 1986 as a no-fault system through 
which families of individuals who suffer injury or death as a result of adverse reac- 
tions to certain childhood vaccines can be compensated without having to prove neg- 
ligence on the part of those who made or administered the vaccines. 

BHPr maintains a federally sponsored health practitioner data bank on all disci- 
plinary actions and malpractice claims. The National Practitioner Data Bank 
(NPDB) was created by The Health Care Quality Improvement Act of 1986, Title IV 
of P.L. 99-660, as amended November 1986. The Act authorized the Secretary of 
Health and Human Services to establish a data bank to ensure that unethical or 
incompetent medical and dental practitioners do not compromise health care qual- 
ity. The NPDB is a central repository of information about: malpractice payments 
made on behalf of physicians, dentists and other licenses health care practitioners; 
licensure disciplinary actions taken by State medial boards and State boards of den- 
tistry against physicians and dentists; and adverse professional review actions taken 
against physicians, dentists, and certain other licensed health care practitioners by 
hospitals and other health care entities, including health maintenance organiza- 



167 



tions, group practices, and professional societies. The NPDB opened on September 1, 
1990. 

TARGETED SUPPORT FOR GERIATRICS 

In FY 1992, 27 Geriatric Education Centers (GECs) received grants under section 
789(a) of the PHS Act, an authority which specifically authorizes geriatric training. 
Many centers are consortia or other organizational arrangements involving several 
academic institutions, a broad range of health professions schools, and a variety of 
clinical facilities. 

The Centers are based at the following institutions: 
University of Alabama at Birmingham, Birmingham, AL 
Stanford University, Stanford, CA 2 
University of California, Los Angeles, CA 2 
University of Colorado, Denver, CO 
University of Miami, Gainesville, FL 
University of Illinois, Chicago, IL 
Indiana University, Indianapolis, IN 
University of Kentucky, Lexington, KY 
Harvard Medical School, Boston, MA 
University of Minnesota, Minneapolis, MN 
University of Mississippi Medical Center, Jackson, MS 
St. Louis University, St. Louis, MO 

University of Medicine and Dentistry of New Jersey, Stratford, NJ 

Research Foundation of SUNY 2 

Research Foundation of CUNY 2 

Bd of Regents, Univ. of NV, Reno 2 

Case Western Reserve University, Cleveland, OH 

University of Oklahoma, Oklahoma City, OK 

Oregon Health Science Center, Portland, OR 

University of Pennsylvania, Philadelphia, PA 

University of Pittsburgh, Pittsburgh, PA 2 

Meharry Medical College, Nashville, TN 

Baylor College of Medicine, Houston, TX 

University of Texas, San Antonio, TX 

Virginia Commonwealth University, Richmond, VA 

University of Washington, Seattle, WA 

Marquette University 2 

Awards for these 27 GECs totaled $9,298,927 for fiscal year 1992. Funding for 
fiscal year 1993 under Section 777(a) is expected to be approximately $5.5 million. 
These Centers are educational resources providing multidisciplinary geriatric train- 
ing for health professions faculty, students, and professionals in allopathic medicine, 
osteopathic medicine., dentistry, pharmacy, nursing, occupational and physical ther- 
apy, podiatric medicine, optometry, social work, and related allied and public or 
community health disciplines. They provide comprehensive services to the health 
professions educational community within designated geographic areas. Activities 
include faculty training and continuing education for practitioners in the disciplines 
listed above. The Centers also provide technical assistance in the development of 
geriatric education programs and serve as resources for educational materials and 
consultation. 

GERIATRIC ACTIVITIES SUPPORTED UNDER BROADER TRAINING AUTHORITIES 

Division of Associated, Dental and Public Health Professions 

This Division funds education projects for a wide array of health providers. The 
General Dentistry Training Grant Program (section 785) currently supports 32 post- 
doctoral residency and advanced education programs in dentistry, which include 
training opportunities to provide dental care to the elderly. In awarding $3,252,561 
in FY 1992 grants, a funding priority was given to applicants who proposed to fur- 
ther expand and improve the geriatric training components of their postdoctoral 
programs. 

Under section 799A, the grant program for Interdisciplinary Training for Health 
Care for Rural Areas has as one of its goals improving access to and availability of 
health care for the residents of rural communities. A funding priority for this grant 
program is given to applicants who include curriculum elements that address the 



2 Indicates New Centers. 



168 



uniqueness of health conditions and the ethnic/cultural characteristics of the popu- 
lations within the rural areas where training/ service is occurring. This provision in- u 
eludes the health of older Americans, and is reflected generally in funded projects. [ 

The University of Hawaii at Manoa School of Social Work received $126,606 for a 
project cosponsored by the Hawaii Department of Health. The project is establishing J 
a statewide coordinated structure for rural health care providers and interfaces 
with the Pacific Islands Geriatric Education Center and Area Agencies on Aging. 
Activities will increase the knowledge base of providers on the needs of special rural 
populations, including the elderly. 

The University of Nebraska Medical Center College of Dentistry received $79,768 
for the development of clerkships of rotating interdisciplinary training experiences 
in rural Nebraska. This project, which involves significant geriatric emphasis, will 
provide special didactic course work in the social aspects of health care delivery to 
elderly and ethnic minority individuals, including migrant workers. Collaborative 
arrangements exist with the Nebraska Department on Aging and the Nebraska 
Geriatric Education Center. Existing area training sites serving a significant popula- 
tion of elderly persons will be used in the implementation of project objectives. The 
evaluation team includes representatives of the Omaha Gerontology Program. 

The University of North Dakota School of Medicine received $124,159 for a project 
which proposed to increase recruitment and retention of nurse practitioners, physi- 
cian assistants, and social workers in designated health manpower shortage and 
frontier areas of North Dakota. Continuing education for practitioners in isolated 
areas through the use of teleconferencing will include topics such as alcoholism in 
the elderly and the impact of geographic isolation upon the management of Alzhei- 
mer's Disease among the elderly. 

Vanderbilt University received $147,446 to establish a nurse case-managed pri- 
mary care clinic to serve as a clinical practicum site for graduate nursing and phar- 
macy students as well as family practice residents. The clinic will serve a predomi- 
nantly black population and be used as a preceptored learning laboratory for geron- 
tological nurse practitioners and gerontological psychiatric/mental health nurses, 
among others. ' 

The West Alabama Health Services, Inc., received $209,228 for a collaborative 
project with the University of Alabama to develop an interdisciplinary training pro- 
gram to enhance the quality and availability of health care services and to retain 
health care providers in the rural western part of the State. Trainees will undergo 
substantial interdisciplinary geriatric training. 

Husson College in Maine received a grant for $229,949 to develop and evaluate a 
community-based interdisciplinary geriatrics assessment and therapeutic service. 

Other grants awarded under section 799A include curriculum development and/ or 
training seminars on gerontology and health care needs of the elderly. 

Allied Health Special Project Grants under section 796 have several purposes re- 
lated to the aged: number 2 — "to improve and expand enrollment in professions 
with greatest demand and most needed by elderly"; number 3 — "interdisciplinary 
training programs that promote allied health in geriatrics and rehabilitation of el- 
derly"; number 5— "adding and strengthening allied health curriculums in preven- 
tion and health promotion, geriatrics, long-term care, home health and hospice care, 
and ethics." 

Several of these grant programs include activities to strengthen academic and 
clinical curricula in the areas of geriatrics and long term care, and to increase the 
geriatric knowledge and skills of their didactic faculties. 

Howard University in Washington, D.C., has a $94,463 grant titled "Multi-tiered 
Geriatric Education and Training Project." This grant addresses the need for geriat- 
ric literacy, interdisciplinary skills in response to the needs of the elderly, and 
strengthening curriculum units relative to geriatrics content throughout the College 
of Allied Health Sciences. The objectives of the grant are: (1) to impact the geriatric 
knowledge and skills of the didactic faculty; (2) to promote interdisciplinary geriat- 
ric care among clinical faculty; (3) to enable faculty to infuse geriatric content 
throughout the professional curriculum; (4) to impact student learning via January 
semester in geriatrics and subsequent geriatric experiential learning; and (5) estab- 
lish faculty/student geriatric assessment teams. 

Indiana University School of Medicine has a $83,525 grant to strengthen existing 
curricula and expand enrollment in programs preparing allied health practitioners. 
Objectives include: (1) strengthening allied health programs through faculty devel- 
opment activities; (2) expanding enrollments which commonly serve the elderly (oc- 
cupational therapy, physical therapy and respiratory therapy); (3) strengthening 
curricula in all nine allied health program areas offered by the Division of Allied 
Health Sciences and offering an interdisciplinary course in geriatrics for those pro- 



169 



fessions which most commonly care for the elderly; and (4) enhancing recruitment 
to all the allied health programs through a series of health professions career days 
and guidance counselor information sessions with special emphasis on minority re- 
cruitment through the establishment of a minority student association and minority 
mentor network. 

Langston University in Langston, Oklahoma, a Historically Black College or Uni- 
versity, received a $57,021 grant titled "Enhancement of Faculty, Curriculum, and 
Students." Activities include strengthening academic and clinical curricula in the 
areas of health prevention and promotion, geriatrics, long-term care, home health, 
and hospice care. 

Clark County Community College, Southern Nevada has a $15,798 grant titled "A 
Wellness-Centered Geriatrics Specialist Program." This grant is designed to imple- 
ment an interdisciplinary modular approach to address allied health care training 
to serve the needs of an aging population. Objectives include: (1) developing interdis- 
ciplinary instructional modules on geriatrics for allied health practitioners and fac- 
ulty that emphasize wellness and healthy aging; (2) delivering instructional modules 
to a minimum of 60 allied health practitioners and faculty; (3) providing a total 
learning environment for students in the geriatric instructional modules to gain a 
more positive attitude about aging and increased willingness to work with the 
senior adult client; and (4) developing continued community support. 

The University of North Carolina at Chapel Hill received a grant for $110,888 to 
develop a model geriatric clinical education program in allied health entitled "Geri- 
atric Education Research and Practice in Physical Therapy." 

Under the program for Faculty Training Projects in Geriatric Medicine and Den- 
tistry (section 789(b)), 16 grantees received $4,040,419 to provide geriatric faculty 
training experiences for 74 fellows. Participants were trained in either 2-year fellow- 
ships or 1-year retraining projects which included clinical, teaching, administrative 
and research skills pertaining to geriatrics. 

Division of Medicine 

The Division continues to support through its grant and cooperative agreement 
programs significant educational and training initiatives in geriatrics. 

Twelve predoctoral grantees and 98 graduate program grantees under section 
786(a), Family Medicine Training, indicated that they are actively involved in the 
development, implementation and evaluation of their geriatrics curriculum and 
training. Twelve of the predoctoral grantees received funds totaling $527,470, and 3 
of the residency program grantees received funds totaling $160,568 specifically for 
developing and enhancing geriatrics curriculum and training experiences. In addi- 
tion, 12 faculty development programs reported that they provided geriatrics train- 
ing. Four of the section 780 Family Medicine Departments program grantees re- 
ceived awards totaling $302,382 for the purpose of strengthening geriatric training 
and carrying out research activities in this area. 

Under section 784, the General Internal Medicine and General Pediatrics Residen- 
cy Training Programs reported 6 grantees who provided geriatric medicine training. 
A total of $42,464 was awarded. 

The Area Health Education Center (AHEC) Program (section 781) awarded a total 
of $17,309,412 to the 20 AHECs. Approximately 5 percent of these awards support 
geriatric activities. Trainees include all health professions students at all levels and 
practitioners. In addition, the AHEC special initiatives program awarded two grants 
totaling $198,928 to develop programs targeted to health care issues of the elderly 
which impacted 950 trainees. Activities include training of nursing home staff and 
hospital staff. Training sites involve public health departments/clinics and other 
ambulatory care sites. 

Seven Physician Assistant Training Program (section 788(d)) grantees have insti- 
tuted training activities in geriatrics. These grantees were awarded $116,450 specifi- 
cally for their efforts in this area which affected an estimated 433 trainees. 

Six grantees receiving support for Podiatric Primary Care Residency Training 
under section 788(e) authority have included curricular emphasis in geriatric health. 
These grantees received a total of $475,000. 

Geriatrics training components will be developed by 4 of 13 grantees under the 
Health Education and Training Centers Program (section 781(f)). A total of 
$3,911,000 was awarded for this program. Approximately 3 percent of this amount 
involved geriatric activities related to geriatrics impacted an estimated 650 trainees 
including physicians, social workers, nurses, community health worker, and public 
health trainees. 



170 



Division of Nursing 

The Division of Nursing continues to administer grants awarded through four pro- 
grams: (1) Advanced Nurse Education, (2) Nurse Practitioner and Nurse-Midwifery, 
(3) Special Projects, and (4) Professional Nurse Traineeships. The fourth program 
provides funds to schools which allocate these funds to individual full-time master's 
and post-master's nursing students who are preparing to be administrators, educa- 
tors, researchers, nurse-midwives, nurse practitioners, nurse anesthetists, or other 
types of nurse specialists. 

Activities relating to the aging in each of these programs during FY 1992 include: 

The Advanced Nurse Education Program (section 821) authority supported 11 
grants totaling $1,693,717 for gerontological and geriatric nursing concentrations in 
programs leading to a master's or doctoral degree in nursing. Graduates of these 
programs are prepared broadly to meet a wide range of needs relative to the elderly 
in many settings, but are particularly prepared to deal with the older individual 
who is acutely ill. In addition, the program prepares nurses who can teach and do 
research in this important field. 

Under the Nurse Practitioner and Nurse-Midwifery Program (section 822(a)) 11 
master's or post-master's gerontological nurse practitioner programs received 
$1,415,435 in grant support. As nurses with advanced academic preparation and 
clinical training, they are prepared as primary health care providers to manage the 
health problems of the elderly in a variety of settings, such as long-term care facili- 
ties, ambulatory clinics and the home. They provide nursing care which includes the 
promotion and maintenance of health, prevention of disease, assessment of health 
needs, and long term nursing management of chronic health problems. 

Emphasis is placed on teaching and counseling the elderly to actively participate 
in their own care and to maintain optimum health. 

The Nursing Special Projects Grant Program (section 820) supported 16 projects, 
amounting to $2,198,561, for in-service educational programs for licensed practical 
nurses working with the aged, gerontological training programs for nurse educators, 
and educational programs for practicing nurses in the assessment and management 
of the frail elderly. Project activity was based in acute care settings and in the com- 
munity as well as nursing homes. 

Below is highlighted one of the specific special projects: 

A special project was awarded to Old Dominion University, Norfolk, Va. over a 3- 
year period to compare the effectiveness of utilizing a case management system im- 
plemented by a family nurse practitioner in a mobile health unit to assess, coordi- 
nate and deliver services to individuals 65 years of age or older in a rural setting 
with the current method of providing services. The project will focus on providing 
access to health care services for those individuals who have difficulty obtaining 
care because of illness, transportation problems, or financial factors. The nurse 
practitioner associated with the project will provide nursing services in the home as 
well as at designated community sites via the mobile health unit. 

The proposed project will study changes in access to care, functional status, 
health status, and health promotion behaviors after implementation of the project 
as well as evaluate the impact of the project on the community, and test the cost 
effectiveness of the service delivery model. It is anticipated that data from this 
project will be useful in determining the health status of the rural elderly and pro- 
vide a better understanding of the life conditions affecting health in a rural area. 

A total of 5,337 traineeships were supported through the Professional Nurse 
Traineeship Program (sections 830(a) and (c)). Of this number, 96 were for study in 
gerontological nursing and of 1,165 nurse practitioners involved, 55 are in geriatrics. 
Thus, 151 traineeships or 3 percent were in geriatrics. 

ACTIVE CONTRACTS UNDER TITLE VII AND VIII OF THE PUBLIC HEALTH SERVICE ACT 

Funding FY 1992 

Project 
240-92-0014 

University of South Florida 

"Eighth Workshop for Key Staff of Geriatric Education Centers" 

01/30/92-01/31/92 $128,090 

The purpose of the contract is to plan, develop, and conduct a workshop, including 
logistical support, to enable key staff from both long-existing and newly established 
Geriatric Education Centers (GECs), to interact, exchange information, share strate- 



171 



gies and jointly consider GEC purposes. The workshop focused on identification of 
strategies for accomplishing programmatic functions of GECs including: faculty de- 
velopment, technical assistance, information referral activities, curriculum develop- 
ment, education services in geriatric education, and other topics. Emphasis was 
given also to identification and assessment of issues and solutions in GEC manage- 
ment and organization including methods: of obtaining support from the community 
or area served, for initiating and increasing geriatric content in health professions 
education programs throughout the area served, of stimulating the improvement of 
services to target populations, and investigating how GECs can address emerging 
issues in geriatrics. 

Funding FY 1992 

Project 
92-33KP) 

Case Western Reserve University 

"Elder Abuse Activities in Geriatric Education Centers: 

06/04/92-12/08/92 ! $20,621.13 

The purpose of this project was to: (1) identify and assess the nature and extent of 
program activities (at 31 funded and 12 previously funded Geriatrics Education Cen- 
ters) that related to identification, diagnosis, treatment, and prevention of elder 
abuse and neglect in community and institutional settings; (2) highlight GEC "best 
practice" models of professional education and public awareness with respect to 
elder abuse and neglect; and (3) synthesize Geriatric Education Centers' assessment 
of the need for training of health professions educators and practitioners about 
elder abuse and neglect. 

PUBLICATIONS 

The "Eighth Report to the President and Congress on the Status of Health Per- 
sonnel in the United States 1991" (submitted to Congress September 1992) has a sec- 
tion devoted to Geriatrics. 

The report to Congress entitled "Study Models to Meet Rural Health Care Needs 
Through Mobilization of Health Professions Education and Services Research" 
(June 1992), included a chapter devoted to "The Rural Elderly." 

The Coordinator for Geriatric Education Centers Program, Ms. Ann Kahl, co-au- 
thored a paper, "Geriatrics Education Centers Address Medication Issues Affecting 
Older Adults," in the January/February 1992 issue of the Public Health Report. 

Ms. Kahl also authored the paper, "The Role of Geriatric Education Centers in 
Promoting Multidisciplinary Training in Geriatrics and Gerontology," in the "Ger- 
ontology & Geriatrics Education," Vol. 12(3) 1992. 

Ms. Kahl also served on the Research Resources Technical Workgroup for the con- 
gressionally mandated Task Force on Aging Research. 

FUNDING FACTORS USED IN BHPR TRAINING PROGRAMS 

The Bureau utilizes several funding factors to address national priority areas. 
These factors are designed to place applicants responding to these national needs in 
a more competitive funding position. The following programs used a geriatric fund- 
ing priority in awarding funds in FY 1992: 

Area Health Education Centers (cooperative agreement), section 781(a)(1) 
Area Health Education Centers (special initiatives), section 781(a)(2) 
Podiatric Medicine, section 788(e) 
The following programs used a geriatric special consideration in awarding funds 
in FY 1992: 

Nurse Practitioner/ Nurse Midwifery, section 822(a) 

Geriatric Education Centers, section 789(a) (special consideration relates to 
clinical training in geriatrics rehabilitation) 
Allied Health, section796(a) 

NATIONAL INSTITUTES OF HEALTH— NATIONAL INSTITUTE ON AGING 

The number of Americans age 65 and over is expected to double in the next 40 
years. Providing appropriate, cost effective health care for America's aging popula- 
tion in the years ahead will depend on aggressive efforts to conduct aging research 
and to translate the resulting scientific advances into clinical use. This report high- 
lights a number of research advances made during 1992 by scientists at the Nation- 
al Institutes of Health (NIH), the principal medical research arm of the Federal 



172 



Government. Among the NIH institutes, the National Institute on Aging (NIA) is 
the central sponsor of aging research in the United States. The first section of this 
report covers recent achievements in Alzheimer's disease (AD), one of the chief re- 
search priorities at NIA. The second section describes new findings on cardiovascu- 
lar disease, genetic developments, prostate cancer, osteoporosis and calcium deficien- 
cy, the pneumococcal vaccine, and other concerns affecting older people. 

Alzheimer's Disease 

AD poses enormous challenges to those with the disease, their families, and to our 
Nation's health care providers. Although the disease today cannot be prevented or 
reversed, promising research is under way to reveal its causes, to improve diagnostic 
techniques, and to find effective treatments. 

Scientists estimate that 4 million Americans suffer from AD, a slowly degenera- 
tive brain disease that impairs memory, attention, and judgment. Most persons with 
AD are age 65 or older, and risk of developing the disease increases with advancing 
age. As we approach the 21st century, the number of older Americans is growing 
rapidly. It is estimated that the number affected by AD may rise to as many as 14 
million by the middle of the next century, as medical advances and lifestyle changes 
increase the number of people living to a very old age. 

AD costs the Nation an estimated $90 billion each year, including medical bills, 
nursing home costs, home care costs, and lost productivity. The overall cost of the 
disease can be expected to escalate dramatically over the next several decades as 
health care costs increase generally and the population ages. 

The financial costs are small, however, compared to the human toll taken by this 
disease. Patients face the inevitability that their "self is disintegrating. Caregivers 
face the despair of seeing their loved ones' minds and personalities fade as they 
become totally dependent. Families frequently assume difficult physical and emo- 
tional burdens, as well as economic hardships, in caring for patients over prolonged 
periods that average from 8 to 20 years. 

In the face of hardship there is increasing hope as researchers intensely pursue 
the clues that will allow them to unlock the mysteries of AD. A better understand- 
ing of the role genetics may play in the disease, new discoveries about proteins im- 
plicated in the death of brain cells, increasingly accurate diagnostic approaches, and 
potential treatments currently in development are all the result of hours spent at 
the laboratory bench and in clinics with patients and their families. As scientists 
learn more about the disease, this knowledge will be translated into approaches to 
help persons with AD live as fully as possible for as long as possible and help relieve 
the burdens of care borne by their families. 

The advances of 1992 bring us a step closer to these goals and provide a firm foot- 
ing for the discoveries ahead in 1993. Key AD research in 1992 included an in- 
creased understanding of the role of the amyloid precurser protein (APP) in tlie de- 
velopment of AD, improvements in diagnostic techniques, cross cultural research de- 
signed to identify risk factors, potential treatments, and an in-depth look at the 
impact of special care units on people with AD. 

This report provides highlights of research supported by or conducted at NIH 
through NIA; the National Heart, Lung, and Blood Institute; the National Institute 
of Diabetes, Digestive, and Kidney Diseases; the National Institute of Neurological 
Disorders and Stroke; the National Institute of Allergy and Infectious Diseases; the 
National Institute of Arthritis, Musculoskeletal, and Skin Diseases; the National In- 
stitute on Deafness and Other Communication Disorders; the National Institute of 
Mental Health; the National Center for Research Resources; and the National 
Center for Nursing Research. Other research on AD is being conducted by the na- 
tional Cancer Institute; the National Institute of Dental Research; the National In- 
stitute of Child Health and Human Development; the National Eye Institute; the 
National Institute of Environmental Health Sciences; the National Center for 
Human Genome Research; and the Fogarty International Center. 

The National Center for Human Genome Research (NCHGR), the NIH component 
charged with overseeing the Human Genome Project, supports the development of 
research tools that make the search for disease genes faster, easier, and cheaper. 
Recently, an international team of investigators, which included NCHGR grantees, 
published a complete map of the gene-containing portion of chromosome 21, one "of 
the chromosomes linked to familial AD. NCHGR supports several investigators who 
are improving the detail on this map, which will help pinpoint the location of sus- 
pect genes and provide a basis for analyzing cloned DNA pieces representing the 
region where genes reside. 



173 



THE STRUCTURE AND FUNCTION OF THE BRAIN 

The human brain is a complex organ that controls behavior, movement, feelings, 
and senses. It is the basis for the human ability to speak, move, understand, and 
remember. The brain also controls functions we may not always be aware of, such 
as breathing and swallowing. 

The brain is an intricate network that contains billions of nerve cells called neu- 
rons. These neurons are the building blocks of a complex communication system 
that relays messages within the brain and between the brain and the rest of the 
body. Each neuron consists of a cell body, axon, and dendrites. Within the center of 
the cell body is a nucleus. Each cell has a long extension called an axon, which 
transmits chemical messages to other cells. Branch-like ends extending from the cell 
body, called dendrites, receive these communications from other cells. The messages 
are transmitted by chemical messengers called neurotransmitters from the axons of 
one cell to the dendrites of another across a gap between cells, called the synapse. 
In AD, this complex process of communication between cells breaks down. 

Groups of neurons are located throughout the brain. In AD, the areas of the brain 
that appear to be particularly affected are parts of the cerebral cortex and the 
hippocampus. The cerebral cortex is the outer layer of the brain. The areas of the 
cerebral cortex responsible for cognitive functions such as language are most affect- 
ed in AD. The hippocampus is located deep in the brain and is believed to play an 
important role in memory. Unlike most other cells in the body, neurons are long- 
lived but cannot be replaced if they die. Therefore, death of neurons in these impor- 
tant parts of the brain of a person with AD has a severe impact on memory, cogni- 
tion, and behavior. 

UNRAVELING THE MYSTERIES OF PLAQUES AND TANGLES 

Dr. Alois Alzheimer's description of the disease that we now call AD was based on 
his examination of the brain of a middle-aged woman who had developed symptoms 
of dementia prior to her death. Alzheimer noted two types of abnormal structures in 
the brain: amyloid plaques and neurofibrillary tangles. Today, the presence of these 
structures in the brain remains the pathological criteria for a diagnosis of AD. Since 
Dr. Alzheimer's discovery in 1907, scientists have studied these plaques and tangles 
extensively in an attempt to understand their location, form, structure, composition, 
and relation to normal brain structure. 

Plaques and tangles have provided clues to the process of the disease and possible 
causes. Plaques contain dense deposits made up of a protein known as amyloid, as 
well as other associated proteins. In AD, amyloid plaques are found in areas of the 
brain associated with memory. Neurofibrillary tangles are collections of twisted 
nerve cell fibers, called paired helical filaments, found in the cell body of neurons. 
In addition to neurofibrillary tangles, paired helical filaments can be found in neur- 
ites, finger-like extensions from the cell body. Recently, scientists have analyzed 
these filaments to learn more about their chemistry and what role they may play in 
the disease. 

A protein called beta-amyloid peptide is the major component of the amyloid 
plaques that fill the brain in AD. This protein is derived from a much larger pro- 
tein, the amyloid precursor protein. Scientists do not yet know how beta-amyloid 
peptide is produced from APP or why it accumulates in plaques. Until recently, 
they thought that beta-amyloid peptide formed only in the brains of people with 
AD. Researchers at several laboratories, including those of NIA grantees Dr. Dennis 
Selkoe at Brigham and Women's Hospital in Boston, Massachusetts, and Dr. Steven 
Younkin at Case Western Reserve University in Cleveland, Ohio, have discovered 
that beta-amyloid peptide is produced and secreted normally by a variety of cells 
and is also found in cerebrospinal fluid and blood. Thus, rather than simply the 
presence of beta-amyloid peptide, the rates at which it is made, secreted, accumulat- 
ed, and removed may be important in the formation of amyloid plaques. With this 
knowledge, drugs that affect these rates can be tested in cell culture systems. 

MUTATIONS IN THE AMYLOID PRECURSOR PROTEIN PROVIDE CLUES 

An important link between APP and the development of AD has been identified. 
Family in which early onset AD is inherited have been known for years. Recently, 
several of these so-called FAD families (familial AD) have been shown to carry one 
of a few rare mutations in the APP gene. In these families, the presence of the mu- 
tation appears to be linked specifically to the development of dementia in middle 
age. 

Researchers recently identified a mutation in the APP gene in two Swedish FAD 
families. This mutation brings the number of known mutations in the APP gene to 



174 



seven; four appear to cause early onset AD and two cause cerebrovascular disease 
with or without dementia. The seventh APP mutation has not yet been shown to be 
clearly associated with the disease. Research on these mutations identified in the 
APP gene is discussed further in sections of this report highlighting work supported 
by other institutes. 

A pattern appears to be emerging in the APP mutations — so far, the mutations 
seem to be concentrated near the beta-amyloid peptide region of the APP gene. Sig- 
nificantly, three of these mutations affect the identical site in the APP protein. 

Although it is not clear whether beta-amyloid peptide is responsible for the death 
of brain cells, the association of APP mutations with some FAD families has strong- 
ly implicated some aspect of APP as a factor in the etiology of AD. 

ADDITIONAL ALZHEIMER'S GENE IS IDENTIFIED 

NIA grantee Dr. Gerard Schellenberg and colleagues at the University of Wash- 
ington in Seattle have recently obtained evidence for an additional AD gene. They 
showed that inheritance of AD in a group of early onset FAD families was closely 
linked to a gene in a small region of chromosome 14. Determining the identity of 
this gene could represent a major step toward understanding the origin and develop- 
ment of AD. Previous FAD mutations have been identified only in the APP gene. It 
is possible that the chromosome 14 gene may be involved in the processing of APP. 
It is equally possible that this gene will point researchers toward a previously unsu- 
spected mechanism operating in AD. 

CALCIUM-ACTIVATED PROTEASES IMPLICATED IN DEVELOPMENT OF AD 

Dr. Ralph Nixon and colleagues, grantees at McLean Hospital in Belmont, Massa- 
chusetts, have reported widespread and early changes in calcium-activated proteases 
in the brains of people with AD. Proteases are enzymes involved in the breakdown 
of proteins. The researchers found that the level of calcium-activated protease in the 
AD brain was elevated three-fold. Proteolysis, or the breakdown and processing of 
proteins into small fragments, has been implicated in various ways in AD. Calcium- 
activated proteases may contribute to the altered protein processing and protein 
phosphorylation found in plaques and tangles in the AD brain. In phosphorylation, 
phosphates are added to specific sites on proteins, a process that has significant ef- 
fects on cellular metabolism. 

ESTROGEN MAY PLAY A ROLE IN AVOIDING CELL DEATH 

Findings by grantee Dr. C. Dominique Toran-Allerand at Columbia University in 
New York suggest that estrogen may play a role in AD. Neurons that are affected 
in AD have estrogen receptors, as well as receptors for nerve growth factor. What- 
ever initiates the breakdown of neurons in AD, cell dysfunction and death are the 
final result. If estrogen is involved in maintaining the function of neurons which 
are at risk in AD, this would have important therapeutic implications. This re- 
search also raises the question of whether estrogen deficiency may make post-meno- 
pausal women more vulnerable than men of the same age to AD, as some epidemio- 
logical studies have suggested. 

IMPROVING DIAGNOSTIC TECHNIQUES 

At present, there is no test to diagnose AD in living patients. The appearance of 
plaques and tangles can be noted only by examining brain tissue. This means that 
AD is a diagnosis of exclusion, which is confirmed on autopsy in about 80 to 90 per- 
cent of probable AD cases. A probable diagnosis of AD is based on the patient's med- 
ical history, a physical examination, and tests of mental ability. A thorough diag- 
nostic examination is important, because although AD is the most common type of 
dementia experienced by older persons, it is not the only cause of dementia-like 
symptoms. A stroke, depression, vitamin deficiency, medication reaction, viral infec- 
tion, and a condition called normal pressure hydrocephalus can cause symptoms 
closely resembling AD. These conditions require different treatments, and in some 
cases the symptoms can be reversed. Only by ruling out these conditions can a diag- 
nosis of probable AD be made. 

Researchers have been striving to develop an accurate test to diagnose AD in 
living patients. NIA grantees, including Dr. William Van Nostrand of the Universi- 
ty of California, Irvine, and Dr. Merrill Benson and colleagues at Indiana University 
in Indianapolis, have pinpointed a reduction in the levels of a derivative of APP, 
called PN-2, in the cerebrospinal fluid of persons with familial AD compared to 
their unaffected siblings. Researchers believe it may be possible to use this result to 
devise a biochemical diagnostic test for the disease. 



175 



CONSORTIUM TO ESTABLISH A REGISTRY FOR ALZHEIMER'S DISEASE (CERAD) HITS THE 

1,000 MARK 

In 1992, the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) 
registered its 1,000th case. CERAD is working to bring uniformity to the clinical 
study of AD by standardizing clinical, neuropsychological, neuroimaging, and neuro- 
pathological assessments. Since 1986, the CERAD network has expanded from its 
original 14 sites to 23 clinical sites throughout the country. 

A highlight of recent activity is the CERAD Dementia Assessment Packet, which 
includes a detailed clinical examination, differential diagnosis criteria, and data 
forms for all the major dementias. The packet also includes tests sensitive to possi- 
ble early symptoms of AD and the Behavior Rating Scale, developed to assess the 
psychiatric symptoms of dementia. Specific guidebooks have been developed to be 
used in neuropathological and neuroimaging assessment. 

Well on the way to meeting many of their original goals, CERAD investigators 
have expanded the focus of their research to look at a broader range of major de- 
mentias of older people. In addition, CERAD is expanding internationally, with a 
number of projects currently under way in Canada and France. CERAD assessment 
tests have been translated into seven languages, and a new component of the 
project, CERAD International Associates, has recently been established. This new 
component will develop international clinical resources at major medical centers for 
future collaborative multinational and cross-cultural research on AD and related de- 
mentias. 

EARLY MARKERS OF ALZHEIMER'S DISEASE (EMAD) PROGRAM 

Led by Dr. Paul Coast, intramural researchers at the NIA Laboratory of Personal- 
ity and Cognition (LPC), Early Markers of Alzheimer's Disease (EMAD) Program 
have made significant progress in their attempts to identify signs of AD. Working 
with participants in the NIA Baltimore Longitudinal Study of Aging, researchers 
examined changes in immediate visual memory performance as assessed by the 
Benton Visual Retention test. Compared to participants without AD, people with a 
diagnosis of AD had a greater change in number of errors over the 6-year retest 
interval prior to the estimated onset of the disease. These results suggest that AD 
may be manifested by changes in immediate visual memory performance earlier 
than it is currently detectable by clinical evaluation. Replication of these findings is 
an important priority for ongoing and future research. 

POTENTIAL LINK IDENTIFIED BETWEEN LEVEL OF EDUCATION AND AD 

Dr. Yaakov Stern and colleagues, grantees at Columbia University in New York, 
have investigated the relationship between level of educational attainment and AD. 
Researchers propose that education may actually provide a reserve of cognitive ca- 
pacity that delays the clinical symptoms of AD. Researchers measured the cerebral 
blood flow of a group of people who appeared to have comparable levels of dementia. 
Despite the fact that they seemed to have similar symptoms of AD, patients with a 
greater number of years of education had a more advanced level of brain deteriora- 
tion than those with fewer years of education. The researchers concluded that edu- 
cation may provide a reserve that compensates for the neuropathological changes in 
AD and may delay the onset of its symptoms. 

RISK FACTORS ARE THE FOCUS OF CROSS-CULTURAL STUDY 

NIA grantees Dr. Hugh Hendrie of Indiana University in Indianapolis and Dr. 
Benjamin Osuntokun of the University of Ibadan, Nigeria, are working together to 
discover possible risk factors for AD. This cross-cultural study is the first to focus on 
African-Americans and Nigerians at risk for the disease. 

One objective of the study is to determine whether the prevalence and incidence 
of AD is lower in the Nigerian than in the African- American population. Research- 
ers will collect data on the most common physical signs of AD in the brain-plaques 
and tangles. They suspect that these lesions may differ in size and number in Nige- 
rians with Alzheimer's than in African-Americans for reasons that have yet to be 
determined. Valuable information may be forthcoming from any differences that 
are observed. 

Researchers are particularly interested in noting if some risk factors are common 
to people in both locations, or if the number of cases in both locations is associated 
with certain risk factors. They hope that some risk factors, which are widespread in 
Westernized societies, will become obvious when comparisons are made between dif- 
ferent societal and cultural environments. 



176 



INITIATIVE IS LOOKING AT SPECIAL CARE UNITS 

While special care units (SCUs), long-term care settings geared specifically toward 
meeting the needs of people with AD, have proliferated across the country in recent 
years, little is actually known about their effectiveness in caring for people with de- 
mentia. To expand the level of knowledge in this area, the NIA has funded 10 
projects nationwide to evaluate SCUs. Among the questions this initiative hopes to 
address are: What effects do SCUs have on people with AD and their family care- 
givers, and on administrators, management, and staff of long-term care facilities? 
How do nondemented residents of nursing homes feel about SCUs? Understanding 
the effectiveness of different types of care will provide important information for 
consumers, family caregivers, and health professionals. It will also assist policy 
makers as they determine how SCUs should be regulated and reimbursed. 

• SITES TEST DEPRENYL AND VITAMIN E FOR AD 

The NIA Alzheimer's Disease Cooperative Study Unit has launched a 23-site 
study to determine whether the drug deprenyl, in conjunction with vitamin E, is 
beneficial for people with AD. At sites located around the country, researchers will 
test this potential treatment with an estimated 370 mild to moderately impaired 
people with AD. 

Deprenyl, also called selegeline or Eldepryl, has been approved for use in the 
treatment of Parkinson's disease. It works by inhibiting an enzyme in the brain that 
impairs certain neurotransmitter systems. In studies with laboratory rats, it has 
also been shown to increase life span, possibly by preventing oxidative damage to 
brain cells. Oxidative damage, which researchers suspect may occur in AD, happens 
when oxygen-free radicals break down nerve cell membranes. Vitamin E appears to 
counteract the destructive oxygen free radicals once they are formed. 

TACRINE TRIAL RESULTS ARE PUBLISHED 

Tacrine, also called tetrahydroaminoacridine or THA, is a drug that increases the 
amount of the neurotransmitter acetylcholine in the brain by inhibiting acetylcho- 
linesterase, an enzyme that breaks down acetylcholine. Tacrine was evaluated as a 
treatment for AD in a large clinical trial initiated in 1987. The multicenter study 
was sponsored collaboratively by the NIA, the Alzheimer's Association, and the 
Warner Lambert Pharmaceutical Co. Recently released results of that trial and an- 
other independent trial indicate that Tacrine may be beneficial in reducing some 
symptoms in some people with AD. In the collaborative study group, researchers 
were able to note a positive response on a measure of cognitive ability. However, 
this group found no effect on a measure of global clinical change. 

In a second study, researchers reported positive effects on both cognitive and 
global measures. These results suggest that the treatment effect of Tacrine may be 
clinically significant in some patients. Future studies are needed to further deter- 
mine the role of Tacrine in treating patients with AD and to identify which patients 
are most likely to benefit from this treatment. 

SUSTAINED LOW-DOSE ARECOLINE IS UNDER INVESTIGATION 

NIA intramural researchers are studying the drug arecoline to determine its use 
as a potential treatment for AD. One of the primary neurotransmitter systems af- 
fected by AD is the cholinergic system. Thus, one approach to identifying potential 
treatments has been to study compounds that either stimulate the cholinergic 
system or replace depleted levels of the neurotransmitter acetylcholine. Arecoline 
stimulates the cholinergic system. 

Doctors administer escalating doses of arecoline to participants with AD by con- 
tinuous intravenous infusion over a 2-week period. An optimal dose of arecoline is 
identified and then infused continuously for 5 days. During this time, the partici- 
pant is given a series of neuropsychological tests to determine whether his or her 
performance improves while receiving the optimal dose. Based on preliminary data, 
continuous infusion of an optimal dose of arecoline produces a modest improvement 
in the cognitive functioning of persons with AD. 

RESEARCH ADVANCES IN ALZHEIMER'S DISEASE SUPPORTED AND 
CONDUCTED BY OTHER NIH INSTITUTES 

National Heart, Lung, and Blood Institute 

The National Heart, Lung, and Blood Institute (NHLBI) supports research on the 
normal and abnormal function of blood components. The institute's program in 



177 



thrombosis (blood clotting) and hemostasis (stopping of bleeding) includes studies of 
the blood platelet as a source of APP. In collaboration with the NIA, the NHLBI 
recently initiated basic studies on the biochemistry and molecular biology of APP. 

People with AD have large deposits of amyloid around the neurons and blood ves- 
sels of the brain. The normal function of amyloid and its correlation with AD are 
not known. However, recent studies suggest that it may play a role in hemostasis 
and thrombosis. For instance, researchers have found that blood platelets contain a 
significant amount of APP and that activated platelets release it outside the cell. 
Further, a mutation in APP appears to lead to cerebral bleeding. The possible link 
between AD and blood clotting has been recognized only recently, but evidence indi- 
cates that a precise balance between clotting factors and their inhibitors is essential 
in maintaining healthy brain cells. Scientists hope that basic research on APP will 
elucidate its role in hemostasis and thrombosis and, at the same time, point the way 
toward development of a diagnostic test for AD. 

National Institute of Diabetes and Digestive and Kidney Diseases 

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) 
conducts and supports research on the biomedical, cellular, genetic, and dietary as- 
pects of AD. 

NIDDK-supported researchers have identified a defective gene on chromosome 21 
that appears to be the source of early onset, familial AD. The newly identified mu- 
tation, one of seven mutations identified to date, produces a defect in the APP, 
which may cause an accumulation of beta-amyloid protein in the brains of Alzhei- 
mer's patients. The buildup of this insoluble protein may, in turn, disrupt the trans- 
mission and reception of nerve signals in brain cells, causing the neurologic and 
mental impairment associated with Alzheimer's. 

The researchers believe this finding will shed light on the genetic basis of familial 
AD as well as lead to a further understanding of the more common late-onset AD. 
They plan to transfer the newly found gene into transgenic mice, which could serve 
as animal models for further research into the AD process. Transgenic mice are 
mice that contain a foreign gene, such as the gene that codes for human amyloid 
protein. 

Another NIDDK-supported researcher is studying the role of dietary factors in 
the metabolism of dietary aluminum. The researcher is using rats that have been 
surgically altered to provide a model of impairments associated with aging. The role 
of aluminum in the aging process is not understood, but a buildup of the mineral 
has been found in the brains of persons with AD upon autopsy. 



The National Institute of Neurological Disorders and Stroke (NINDS) is the prin- 
cipal source of support for neurological research in the United States and a major 
participant in the study of AD. NINDS-supported scientists are pursuing a wide va- 
riety of research programs to expand knowledge of this complex disease. Basic stud- 
ies are aimed at determining its underlying causes and effects, while clinical re- 
search seeks to improve the diagnosis and treatment of patients. 



When the causes of a disease are unknown, scientists are often faced with a ques- 
tion of whether tissue abnormalities found in the disease are a cause or result of the 
disease. This question has long been posed about the amyloid plaques found in AD, 
since one form of the amyloid protein found in the plaques is a natural part of the 
healthy nervous system. 

This year, NINDS-supported scientists found that part of the protein itself can 
cause Alzheimer-like degeneration in mouse brain tissue. The investigators used the 
gene for the amyloid precursor protein (APP) to make cells that produce a portion 
of the amyloid protein. Four months after the cells were transplanted into laborato- 
ry mice, the animals' brains showed significant tissue degeneration. In addition, 
brain tissue contained other proteins commonly found in AD, demonstrating that 
this portion of the Alzheimer amyloid protein could replicate many aspects of AD. 

The same investigators have also found that this portion of the APP binds specifi- 
cally to the surface of neurons. They hypothesize that this binding may be the 
result of attachment to a cell surface receptor. This receptor may, in turn, activate 
machinery in the cell that leads to the cell's destruction. If this hypothesis is vali- 
dated, it may lead to a potential therapy that involves blocking these proteins from 
binding to neural cells. 



NationaiI Institute of Neurological Disorders and Stroke 




sctentists study plaques and tangles for the cause of ad 



178 



Another group has found that protein phosphorylation may regulate the secretion 
of APP. This finding offers the hope of eventually blocking the accumulation of 1 
amyloid plaques by hindering the secretion of APP. 

The other hallmark of AD, neurofibrillary tangles, is associated with irregular- g 
ities in a protein called tau, a protein naturally found in the healthy body. Investi- I 
gators supported by the NINDS have discovered that neurofibrillary degradation in | 
AD is likely caused by an abnormal chemical change in tau, rather than by a de- 
crease in the amount of tau in the brain. 

Scientists have recently proposed that the cause of AD might be found in the mi- 
tochondria, the cell's powerhouse. Defects in the mitochondria can lead to an energy i 
shortage in the neural cells and atrophy of brain tissue. Last year, a group of inves- 
tigators found evidence of a decrease in the activity of cytochrome oxidase (CO), a 
key mitochondrial enzyme, in people with AD. This year, the theory gained support [ 
when NINDS-supported investigators found that decreasing the activity of CO in 
rats led to a condition with similarities to AD. This finding requires further study 
since another NINDS-supported team could find no reduction in the activity of CO 
in the brain tissue of people with AD. 

GENETIC CLUES FOUND TO BE A CAUSE OF AD 

Now that the human APP gene has been isolated, scientists around the world are 
looking for genetic defects that could explain why the members of some families 
tend to develop AD more than the members of other families. One group of NINDS- 
supported scientists found a specific mutation in the APP gene in three AD patients 
who are members of a family with higher incidence of the disease. The investigators 
don't know yet if this mutation is related to the incidence of disease in this particu- 
lar family. 

INVESTIGATORS SEEK MORE SPECIFIC DIAGNOSES AND TREATMENT 

The diagnosis of AD remains a diagnosis of exclusion. NINDS-supported scientists 
are using advanced brain imaging technology such as positron emission tomography 
(PET), magnetic resonance imaging (MRI), and others to identify markers that 
might eventually help doctors diagnose AD in living patients. 

One such marker was discovered this year by NINDS-supported investigators 
using MRI. MRI works in part by measuring the magnetic properties of the atoms 
that make up the body. The investigators found that one measurement is signifi- 
cantly increased in the hippocampus of people with AD. Furthermore, the amount 
of increase in this measurement correlates with the severity of cognitive impair- 
ment. The use of this marker may serve as a tool to detect, characterize, and follow 
AD in living patients. 

A group of investigators supported by the NINDS is looking for drugs that ampli- J 
fy the effects of the brain's existing cholinergic neurotransmitters rather than re- 
placing depleted levels of these chemical messengers. The group has synthesized a | 
number of compounds that inhibit the enzyme that degrades the neurotransmitter 
acetylcholine in the brain. They found that some of these compounds were stronger 
and more specific than any other drugs currently available for this purpose. These 
findings may provide the basis for future therapeutic strategies. 

National Institute of Allergy and Infectious Diseases 

Although little evidence exists to suggest that AD is caused by an infectious 
agent, similar patterns of tissue destruction are seen in AD and certain infections of i 
the brain. Understanding what underlies these tissue changes is of interest to the 
National Institute of Allergy and Infectious Diseases (NIAID). 

Amyloid, the abnormal protein that accumulates in the fibrous plaques of AD, is j 
also seen in brain tissue of sheep suffering from scrapie, a transmissible degenera- | 
tive brain disease. The value of scrapie research to Alzheimer's is that animal and 
cell culture models can be used to study both amyloid formation and possible thera- 
peutic strategies. NIAID intramural scientists studying scrapie have recently identi- 
fied several chemical inhibitors of amyloid formation, one of which, Congo red, may 
be useful for treating AD. Tests of the therapeutic effects of Congo red are in i 
progress in the scrapie animal model. 

Another researcher has been studying protein components of amyloid in female 
Syrian hamsters, animals that usually die from an overaccumulation of amyloid. 
One of these proteins is also found in the amyloid deposits in AD. The researchers 
have determined that estrogens play a key role in the high production of this pro- 
tein in these hamsters. 



i 



179 



National Institute of Arthritis and Musculoskeletal and Skin Diseases 

The National Institute of Arthritis and Musculoskeletal and Skin Diseases 
(NIAMS) leads and coordinates research efforts against the many forms of arthritis 
and related problems. One focus of NIAMS-supported research is the possible rela- 
tionship between amyloid and certain forms of arthritis. 

In addition to investigating the role of amyloid in arthritis, researchers supported 
by NIAMS are looking at how abnormal amyloid protein is deposited. These amyloid 
protein deposits may cause damage to brain cells and, consequently, AD. Isolation of 
enzymes involved in removing amyloid may lead to an understanding of why one 
type, beta-amyloid, builds up in excess in the brain. Researchers are working to 
identify and purify this enzyme that is thought to be abnormal in persons with AD. 

NIAMS-supported researchers have also produced a transgenic mouse as a poten- 
tial animal model, which can be analyzed for the effects of this foreign gene. If the 
mice develop lesions similar to those seen in AD, researchers can test various thera- 
pies that may inhibit formation of abnormal amyloid proteins. 

National Institute on Deafness and Other Communication Disorders 

The National Institute on Deafness and Other Communication Disorders (NIDCD) 
conducts and supports research on hearing, balance, smell, taste, voice, speech, and 
language. The NIDCD is the focal point for research on the causes and prevention of 
communication disorders associated with AD. 

An NIDCD investigator is studying the physiologic basis for neurolinguistic im- 
pairments in people with AD, Parkinson's disease, and stroke. These people fre- 
quently have problems with complex communication processing such as speech flu- 
ency and sentence comprehension. 

This investigator is specifically studying sentence comprehension, word process- 
ing, and grammatical problems in the language of people with AD. The investigator 
is using positron emission tomography (PET) to examine the pattern of brain blood 
flow during word analysis techniques in healthy people and people with AD. 

Extensive linguistic analyses are being performed to determine how specific dis- 
ease processes and anatomic lesions can interfere with language output and compre- 
hension. These studies will provide new information about how language functions 
are organized in the brain and will lead to potential new strategies for effective 
speech therapy. 

National Institute of Mental Health 

The National Institute of Mental Health (NIMH) AD research program focuses on 
basic neuroscience, genetics and neurobiology, diagnosis and treatment, and stress 
associated with caregiving. Researchers are also comparing normal aging processes 
with the processes that take place in AD. 

NIMH-supported investigators have learned that many of the changes seen in the 
AD brain are also seen in normal aged brains. The key is to understand what differ- 
ences exist in AD. One theory is that there is a disturbance or exaggeration of the 
normal aging processes. Recent research has shown that certain neurotransmitters, 
particularly acetylcholine and somatostatin, are profoundly diminished in the AD 
brain. Several research efforts are focused on learning as much as possible about 
how these substances work and how they interact with each other. 

One of the reasons acetylcholine is decreased is that the neurons that produce the 
compound seem to die prematurely. Why this occurs is largely unknown. Investiga- 
tors have discovered an interesting connection between the embryonic brain and the 
aging brain. In the developing brain, cells and their processes use growth factors 
and trophic molecules as cues to find their correct places and connections as the 
brain is formed. These factors also may be vital for neuronal survival. One factor, 
nerve growth factor (NGF), seems to play a significant role in the support and sur- 
vival of developing neurons that make acetylcholine. This finding, which suggests 
that a dramatic change in NGF concentration during aging may be responsible for 
the loss of acetylcholine-producing neurons, holds promise for treating the disease 
using therapies that target the NGF system. 

Recent work focusing on how APP is processed and regulated suggests that cer- 
tain brain receptors control APP processing by activating protein kinase C. Deficien- 
cies in neurotransmitter systems linked to the processing of this protein might con- 
tribute to the formation of amyloid plaques. The latest finding from these research- 
ers suggests that low levels of acetylcholine contribute to formation of these 
plaques, providing a new target for drug development. This newly envisioned medi- 



180 



cation would not only stimulate (or inhibit) acetylcholine production, but also inter- 
act in regulating amyloid protein production. 

Understanding normal neuronal processes is critical for unraveling the pathologic 
mechanisms of AD. NIMH-supported researchers have shown that a newly discov- 
ered neurotransmitter, called nitrous oxide (NO), is present in larger quantities in 
neurons compared with anywhere else. These scientists believe that excessive pro- 
duction of NO is closely involved in the cell death associated with stroke and dis- 
eases such as AD and Huntington's. The group is also studying drugs that penetrate 
the blood-brain barrier and that could influence brain protein phosphorylation. 

NIMH intramural researchers have discovered that human olfactory neurons — 
nerve cells found in nasal tissue — can be cloned and cultured. Olfactory neurons 
may make a good model for studying AD because they have many features in 
common with nerve cells located in the brain. The cells are easily accessible in the 
nose and can be obtained from living patients with AD. Olfactory neurons also ex- 
hibit the tangles seen in the brains of people with AD. Researchers have already 
detected abnormalities in the way AD patients' olfactory neurons process beta-amy- 
loid. The fact that these cells come from living patients may be instrumental in de- 
veloping and choosing specific drug therapies for individual patients. 

The inability to diagnose AD in its earliest stages limits intervention and treat- 
ment development. Researchers at the University of Washington in Seattle have de- 
veloped a biomarker that uses electronencephalogram (EEG) results. They have 
automated and standardized the process for interpreting and scoring sleep EEG 
data. The biomarker can distinguish mild AD from major depression without cogni- 
tive impairment. 

NIMH intramural scientists have also identified a protein that is present in in- 
creased levels in the spinal fluid of people with AD. This potential diagnostic 
marker, alpha-2-haptoglobin, increases during inflammation and also during prob- 
lems with iron metabolism. 

Investigators at Stanford University in California are using the Folstein Mini- 
Mental State Examination to examine rates of decline in AD. Patients are tested 
every 6 months to determine decline in cognitive functioning, which has been linked 
to both behavioral and physical changes in patients. An increased rate of decline 
has been linked to the phenomenon "sundowning," or nighttime confusion. 

The intramural research program (IRP) is proceeding with a number of new drug 
studies. Studies with scopolamine and other drugs are designed to establish a better 
pharmacologic model of the memory deficit associated with AD. Using imaging stud- 
ies to examine the effects of scopolamine on regional brain metabolism, researchers i 
hope to understand the memory impairment associated with AD. Initial results sug- 
gest altered metabolism in brain regions related to cholinergic functions. 

The IRP program is also seeking a way to combine the modest effects of multiple 
medications to create a more effective overall treatment strategy. In the first pilot 
study, investigators have learned that selected medications can safely be given to- 
gether to people with dementia. Scientists are also continuing to compare the bio- 
chemical and clinical profiles of people with AD and those with depression to under- 
stand the overlap in behavioral symptoms between these two groups. 

Most of the world's population relies on traditional medical practices that have 
evolved over many centuries. 

By taking advantage of this information, the newly established NIMH Psycho- | 
therapeutic Drug Discovery and Development Program is testing plant extracts, 
some of which are currently used in India for memory and dementia — a practice 
dating back many centuries. In recent studies, these extracts have shown activity at 
several brain receptors thought to play a role in memory and cognition. Future 
studies will further characterize the pharmacology of these traditional medications. 

The effects of caring for AD patients on family members have been widely noted. 
Work of NIMH-supported investigators has yielded important information on the 
physiological effects of the chronic stress of caregiving. This information is helping 
researchers understand how stress affects the immune system, increasing the risk of 
flu, infection, hypertension, and cardiovascular disease. Moreover, subgroups of car- 
egivers at risk are being identified. For example, caregivers without adequate social 
support and respite from caregiving are most at risk for compromised immune func- 
tioning. 

National Center for Research Resources 

Resource centers and other funding provided by the National Center for Research 
Resources (NCRR) support a variety of studies focused on understanding and treat- 
ing AD. 




181 



Investigators at the Indiana University General Clinical Research Center in Indi- 
anapolis have found a gene for amyloid protein in two recent generations of a 
family with familial, early onset AD. Analysis revealed a specific mutation — a 
single amino acid substitution of phenylalanine for valine — in the relevant area of 
the APP. The mutation correlated with the presence of AD in all patients studied 
and was absent in Alzheimers's-free family members and 100 unrelated individuals. 
As discussed earlier in this report, the mutation may be the inherited factor causing 
amyloid formation and dementia in people with this form of AD. 

Nerve growth factor (NGF) is a naturally occurring protein that promotes cell 
growth. Information gathered from long-term studies of the efficacy and safety of 
chronic administration of NGF in nonhuman primates will provide the basis for 
future human clinical trials. Four rhesus monkeys at the University of California 
Regional Primate Research Center in Davis have received grafts containing NGF- 
producing cells; the grafts showed response up to 90 days. In continuing studies, the 
end-point will be extended from days to 6 months, and MRI and PET scans will be 
used to monitor graft survival. 

National Center for Nursing Research 

The National Center for Nursing Research supports both basic and clinical re- 
search to maintain and improve the cognitive functions and quality of life of people 
with AD, whether they reside at home or in an institution. 

One of the most tragic symptoms associated with AD is disorientation, a symptom 
that inhibits independence, can result in wandering behavior, and severely burdens 
the caregiver and family. Furthermore, disorientation is often one of the factors con- 
sidered when families decide to institutionalize a person with AD. 

Preliminary results of an NCNR-funded basic research study suggest that disori- 
entation in rats can be modified. Nurse-scientists used a rat animal model to exam- 
ine the effects of damage to the hippocampus. Researchers found that rats without 
hippocampal damage could find a hidden platform in opaque water, even when re- 
searchers attempted to distract them. Brain-damaged rats, however, were easily dis- 
tracted until researchers introduced both visual and auditory signals. The combined 
cues enhanced the brain-damaged rats' ability to find their way to the platform. 
These results suggest the need for future studies on the role that visual and audito- 
ry cues might play in curtailing disorientation in animals and ultimately people 
with AD. 

OUTLOOK 

The discoveries of the past year promise to yield further insight into the causes of 
AD and how it effects the brain. Although scientists cannot predict that prevention 
or a cure is around the corner, they are optimistic that the discoveries of the next 
few years will lead to effective treatments. Because age is a primary risk factor for 
AD, a delay in the onset of the disease or a slowing of its progression could have a 
significant effect on the overall prevalence of AD. While this will require a better 
understanding of the reasons neurons break down and die, it is not an unreasonable 
goal for biomedical researchers. 

Toward these goals, AD research projects for 1993 include a look at the role of 
calcium and glucocortocoids, a type of hormone, in cell death; research on the func- 
tions of the blood brain barrier; and a project to learn more about the effects of oxi- 
dative damage to membranes. Scientists hope that these and other research projects 
will continue to provide the missing pieces to the AD puzzle. 

Understanding Aging 

NIA scientists take a multidisciplinary approach to studying ways to improve the 
diagnosis, treatment, and prevention of health problems experienced by older 
adults. Other NIH institutes who also have an interest in aging research are the 
National Cancer Institute; the National Heart, Lung, and Blood Institute; the Na- 
tional Institute of Dental Research; the National Institute of Diabetes and Digestive 
and Kidney Diseases; the National Institute of Neurological Disorders and Stroke; 
the National Institute of Allergy and Infectious Diseases; the National Eye Insti- 
tute; the National Institute of Environmental Health Sciences; the National Insti- 
tute of Arthritis and Musculoskeletal and Skin Diseases; the National Institute on 
Deafness and Other Communication Disorders; the National Institute of Mental 
Health; the National Institute on Alcohol Abuse and Alcoholism; the National 
Center for Research Resources; the National Center for Nursing Research; and the 
Office of the Director. 



182 



CELLULAR CLUES MAY REVEAL WHY OLDER PEOPLE ARE MORE PRONE TO 
ATHEROSCLEROSIS 

Researchers studying cardiovascular disease (CVD) at NIA's Gerontology Re- 
search Center in Baltimore, Maryland, have found that cellular changes in blood 
vessels may underlie the high incidence of CVD seen in older people. 

CVDs are disorders of the heart and circulatory system. They include high blood 
pressure (hypertension), angina, stroke, and thickening of the arteries (atherosclero- 
sis). Atherosclerosis is caused by the buildup of fatty deposits (plaque) along arterial 
walls. This plaque (made up of cells, as well as cholesterol and other fats and fibrous 
tissue) accumulates and eventually reduces the flow of blood to the heart muscle. 
When an artery is blocked completely, a heart attack occurs. 

NIA's special interest in CVD stems from the major impact this disease has on 
the health of older people, causing almost half the deaths in this population and an 
enormous burden of disability. Moreover, while heart attack has been recognized for 
many years as a health threat to men, it is also a major cause of death in older 
women. 

Intramural scientists Drs. Rebecca R. Pauly, Antonino Passaniti, Michael Crow, 
James L. Kinsella, Nickolas Papadopoulos, Robert Monticone, Edward G. Lakatta, 
and George R. Martin have been examining the effects of age and injury on the vas- 
cular system in experiments using rat models and cells in culture (both rat and 
human). It is believed that in injured blood vessels, endothelial and smooth muscle 
cells 1 lose structural complexity (become dedifferentiated) and are likely to migrate 
and increase in number (proliferate). 

While cells in healthy animals normally exhibit a high degree of complexity and 
organization (are differentiated), dedifferentiation occurs in injured vessels. Dediffer- 
entiated smooth muscle cells turn on the same proteins that are activated by cancer 
cells as they spread to other sites (metastasize), resulting in changes that alter their 
structure and function. Through this process, called invasion, normal blood vessel 
tissue is destroyed. 

In healthy people the smooth muscle cells contract to change the diameter of the 
vessel. But this ability may be lost in certain vascular diseases when smooth muscle 
cells dedifferentiate, proliferate, migrate, and invade surrounding blood vessel tissue 
to form the atherosclerotic lesion. 

Differentiation and dedifferentiation in endothelial and smooth muscle cells 
appear to be regulated in part by interactions involving proteins making up the 
basement membrane on which these cells rest. Dedifferentiated cells produce proteo- 
lytic enzymes that breakdown basement membrane proteins and allow them to 
reach the lumen of the blood vessel. Smooth muscle cells from older animals release 
more of this proteolytic enzyme in culture than cells from younger animals. The 
regulation of this enzyme appears to be different between older and younger ani- 
mals as well. These dedifferentiated cells, no longer under the control of the sur- 
rounding basement membrane, may proliferate freely and contribute to the forma- 
tion and progression of the atherosclerotic lesion. 

The NIA scientists believe their findings can help to further identify the molecu- 
lar events that control dedifferentiation in vascular cells. This would then promote 
development of therapeutic agents to maintain healthy vessels. This study might 
also help researchers better define which factors are associated with the progressive 
buildup and conversion of fatty streaks into advanced stages of atherosclerotic 
plaque. In studying how to reduce plaque buildup within the arterial walls, scien- 
tists may eventually be able to reverse atherosclerosis. 

SCIENTISTS IDENTIFY PROMISING NEW GENE THERAPY VEHICLE FOR MEDICAL TREATMENTS 

We usually take medications orally, by injection, or in certain cases in the form of 
a skin patch. Scientists are now developing a method for administering biological 
substances such as hormones and growth factors through the use of cell-mediated 
gene therapy. This technique involves genetic engineering in which copies of the 
gene for the appropriate human hormone or growth factor are inserted into the ge- 
netic material of cells taken directly from the patient. The inserted genes instruct 
the cells to manufacture the desired hormone or growth factor. When the genetical- 
ly altered cells are returned to the patient, they synthesize and secrete the desired 
hormone or growth factor into the bloodstream for delivery to the entire body. Gene 
therapy holds great promise for a wide range of medical applications in people of all 



1 Blood vessels are made up of a thin sheet of endothelial cells attached to a sheet of base- 
ment membrane that forms the surface on which blood flows. Beneath the endothelial basement 
membrane are layers of smooth muscle cells whose role is to maintain vessel tone. 



183 



ages. By the turn of the century, scientists predict that some forms of cell-mediated 
gene therapy will be in common use in medical practice. 

A major obstacle to gene therapy is the development of effective cellular vehicles 
for the delivery of therapeutic gene products to the patient. NIA grantees are now 
exploring the potential use of muscle cells, called myoblasts, for gene therapy. Dr. 
Helen M. Blau and her colleagues at Stanford University School of Medicine in Cali- 
fornia have found that myoblasts, genetically engineered to contain the human 
growth hormone (hGH) gene, can be reimplanted into the skeletal muscles of the 
original donor mice. Once implanted, the myoblasts become permanently incorporat- 
ed into existing muscle fibers and begin to synthesize and secrete hGH into the 
blood stream. Myoblasts have several advantages compared to other cell types, such 
as fibroblasts and lymphocytes, which have also been used as vehicles for gene ther- 
apy. First, incorporation of the transplanted myoblasts into existing muscle fibers 
where they are nourished by the blood stream extends the in vivo life span of the 
genetically engineered cells several months. This contrasts with genetically engi- 
neered fibroblasts and lymphocytes that have an average life span of only a few 
weeks as they are rapidly destroyed following implantation. Second, myoblasts 
produce high levels of the desired gene product, so are able to sustain significant 
levels of the hormone or growth factor in the blood stream. Recent studies in Dr. 
.Blau's laboratory have shown that significant levels of hGH were sustained for sev- 
eral months in the mice receiving myoblasts containing the hGH gene. 

Dr. Blau's research sets the stage for the development of intervention strategies 
to retard or reverse some of the consequences of human aging. A small clinical trial 
conducted by Dr. Blau and her colleagues has indicated that myoblast-mediated 
gene therapy can be effectively applied to people. One prominent example of such 
an intervention is the treatment of hGH deficiency in older people. Recombinant 
growth hormone injections are currently used to alleviate the muscle wasting and 
loss of bone strength noted in aging adults who are deficient in hGH. Although 
highly successful, current therapy with synthetic hGH is very costly. Myoblast-medi- 
ated hGH gene therapy promises a cost-effective alternative to the multiple hor- 
mone injections. In addition to the potential value of myoblast-mediated gene ther- 
apy in developing effective interventions for aging processes, this type of gene ther- 
apy holds enormous promise for the future treatment of cancers, AIDS, insulin-de- 
pendent diabetes, and genetic diseases. 

GENETICS MAY OFFER A KEY TO AGING AND CANCER THERAPY 

Researchers studying aging on the genetic level are interested in both the genes 
that control the expression of human characteristics and the role they play in aging 
processes. The telomere is currently of interest because of its possible link with cell 
aging. 

Telomeres are the ends of chromosomes, which are found in the nucleus of each of 
the trillions of cells making up the human body. Each chromosome consists of a 
double-stranded DNA (deoxyribonucleic acid) molecule containing genes that deter- 
mine the expression of human characteristics and traits. Telomeres in humans are 
composed of a specific sequence (TTAGGG) repeated thousands of times. They have 
an important stabilizing effect on chromosome structure throughout the life span of 
an organism and are particularly important in protecting chromosomes from enter- 
ing into undesirable rearrangements during chromosome duplication. 

Of significance for the study of aging is the observation that in most human cells 
telomeres shorten in length with each division of the cell. NIA grantees Dr. Carol 
W. Greider at Cold Spring Harbor Laboratory in Long Island, New York, and Dr. 
Calvin B. Harley at McMaster University in Hamilton, Ontario, Canada, found that 
telomeres shorten by a constant amount with each cell division; The remaining 
length of the telomere can predict the number of previous divisions the cell has un- 
dertaken during its life span and the number of future divisions possible before the 
cell loses its ability to divide further. Thus, telomere length may serve as a counting 
mechanism to record cell division. The investigators noted, however, that telomere 
shortening did not occur in nondividing cells, such as neurons in the brain and 
heart muscle cells. Nor did it occur in human sperm cells. Although sperm cells un- 
dergo cell division like other body cells, their telomeres retain their full length 
throughout the cell's life span. This may be made possible by the activation of telo- 
merase, an enzyme present in all cells but inactive in most human cells. 

A direct link between telomere loss and cellular aging has not yet been estab- 
lished, but Drs. Greider and Harley believe they are getting closer to understanding 
the functional roles telomeres play in aging cells. Their central question is whether 
the progressive decrease in telomere length ultimately causes cell aging or whether 
shortening occurs merely as a function of passing time. Other aging experts warn 



184 



i 



that while telomeres may function as cellular timekeepers, human aging is linked ! 
to a number of different processes operating at many levels, and not solely due to | 
one mechanism such as telomere loss. 

In another part of their research, Drs. Greider and Harley along with their col- 
leagues found that telomeres may have an important bearing on the uncontrolled 
growth of cancer cells. When normal human cells become cancerous, immortal cells 
are produced capable of undergoing an infinite number of divisions. Telomere short- 
ening is overcome in the immortal cells by the addition of telomere sequences. In- i 
vestigators believe these additional sequences may be produced as a result of the 
activation of the telomerase enzyme. However, telomerase activity is only one mech- 
anism responsible for maintaining uncontrolled growth in immortal cancer cells; 
many of the cellular mechanisms responsible for this growth still need to be better 
understood. 

The results of these findings on telomeres and telomerase may have a practical 
benefit for cancer patients in the future. Developing therapies that can block pro- | 
duction of telomerase activity in cancer cells is a goal that may be achieved soon. 
Drugs currently being tested to inhibit the AIDS virus may be found to be of use, 
and other types of new drugs are being developed and tested. 

IMPROVED TESTING REVEALS PROSTATE CANCER EARLIER 

Older men can breathe a little easier when they go for their next physical exam. 
Physicians now may be able to detect prostate cancer years earlier than was previ- 
ously possible by monitoring yearly changes in the level of an enzyme, prostate spe- 
cific antigen (PSA). Discovering a prostate tumor early, before it has escaped to 
other parts of the body, can mean the difference between life and death. 

Drs. Jay D. Pearson of NIA, H. Ballantine Carter of The Johns Hopkins Universi- 
ty, and their colleagues found that repeated measurements of PSA can detect 70-75 
percent of prostate cancer as early as 4 years before diagnosis. PSA is produced by 
both normal and cancerous prostate cells, and increases as the volume of prostate 
cells increases. PSA levels are elevated in patients with prostate cancer and with 
benign prostatic hyperplasia (BPH), a common condition in which the prostate be- 
comes enlarged. 

Most middle-age men experience some prostate enlargement, which often causes 
difficult or painful urination and sometimes requires surgery. About 66 percent of 
men over 50 have BPH. Physicians often test PSA levels when the digital exam in- 
dicates a problem. A single PSA measure, however, can be deceiving. Previous stud- 
ies suggest that up to 60 percent of BPH patients may be falsely identified as poten- 
tial cancer cases when based on a single PSA value. This leads to many unnecessary 
biopsies. Dr. Pearson's studies show that more frequent measurements of PSA can 
reduce the error rate in distinguishing between BPH and cancer to about 10 per- 
cent. 

The increase in PSA is far greater in cancer patients than in men with BPH or 
with normal prostates. This is because prostate cell volume doubles within 50 to 200 
days in a prostate cancer patient, while taking between 10 and 15 years to double in 
patients with BPH. In addition, a cancer cell contributes 10 times more PSA to the 
bloodstream than does a BPH cell. Doctors believe that measuring the rate of 
change in PSA levels over time will be a more accurate method of finding prostate 
cancer in its early stages than relying on a single PSA measure. 

Dr. Pearson's group conducted the study using frozen blood samples from partici- 
pants in NIA's Baltimore Longitudinal Study of Aging (BLSA). The BLSA already 
has data from repeated clinical exams on individuals for more than 25 years. The 
researchers studied samples from a total of 54 participants — 18 with prostate 
cancer, 20 with BPH, and 16 who were healthy — and showed that PSA levels in- 
creased exponentially 7 to 9 years before the actual clinical diagnosis of prostate 
cancer. 

This finding may increase the cure rate for prostate cancer,and could have the 
potential of accurately screening for prostate cancer much like mammography does 
for breast cancer. If future research confirms that long-term measures of PSA are 
more accurate than single measurements, it would be a more reliable and less costly 
screening test for early prostate cancer detection. 

Most prostate problems are initially found by a routine digital rectal exam. If a 
growth is detected, the physician follows up with an ultrasound examination and a 
biopsy. If the tissue proves to be cancerous, treatment includes surgery or radiation 
therapy. However, 60 percent of patients have disease outside the prostate by the 
time it is diagnosed clinically, if they rely solely on a digital examination. 

Prostate cancer is the most common cancer found in American men. More than 
130,000 new cases will be diagnosed in the United States this year and about 34,000 



185 



men will die of the disease. If the the disease is detected before cancer cells migrate 
beyond the prostate gland, it can be completely cured, for advanced stages of the 
disease, there is no cure. Thus, this research will affect thousand of men over age 
50, and offer them — and their doctors — a big boost in peace of mind when testing for 
prostate cancer. 

CALCIUM IN CHILDHOOD PROTECTS AGAINST OSTEOPOROTIC FRACTURES 

Osteoporosis is a condition in which bones become thin, fragile, and highly prone 
to fractures. If affects an estimated 25 million Americans, 80 percent of whom are 
women. Each year the disease results in about 500,000 spinal fractures and about 
3,000,000 hip fractures. In addition to the pain, long periods for recuperation, and 
loss of mobility and independence, treatment costs the Nation up to $10 billion each 
year, thus making hip fractures a major contributor to spiraling health care costs. 

A central factor in preventing osteoporosis is high calcium consumption through- 
out life. Increased calcium intake is associated with a greater gain in bone mass 
during childhood. This higher bone mass is important since it protects against 
future osteoporotic fractures. 

NIA researchers recently found that taking in more calcium than the recommend- 
ed dietary allowance (RDA) during childhood could benefit the adolescent skeleton. 
Dr. C. Conrad Johnson, Jr., and colleagues at the Indiana University School of Med- 
icine in Indianapolis snowed that even when a preadolescent child's normal dietary 
calcium intake met the RDA, additional calcium significantly increased the gain in 
bone mass. If this increase in bone mass can be maintained into adulthood, these 
people can expect a lower risk of osteoporotic fractures. 

This study is the first to find a direct link between the amount of calcium con- 
sumed in childhood and skeletal development. The finding poses a tremendous op- 
portunity for an early focus on the prevention of osteoporosis, particularly for grow- 
ing girls. 

According to Dr. Johnston, peak bone mass is a major determinant of bone mass 
later in life, and an increase in peak bone mass could protect the bones from the 
depletion that occurs with aging and menopause. Although family genetics plays a 
major role in determining bone mass, other factors such as exercise and nutrition 
are also important. Dr. Johnston's work followed previous studies suggesting calci- 
um may be important for the development of peak bone mass and that a high-milk 
intake early in life is associated with increased bone mass later on. This study 
looked at whether calcium alone was effective in increasing the rate of bone acquisi- 
tion. 

Dr. Johnston studied 45 healthy identical twin (ages 6 to 14) in a double-blind pla- 
cebo-controlled trial that lasted 3 years. All the children continued with their 
normal diet, which included the average RDA of calcium (800 mg a day for children 
1 to 10 years and 1,200 mg a day for children 11 and older). One child in each twin 
pair received an average of 700 mg extra calcium each day. The supplemental calci- 
um came from calcium citrate malate. According to researchers, this form of calci- 
um has been shown to be absorbed well in children and young adults and to slow 
bone loss in older women. 

All the children showed substantial increases in bone density throughout the 
course of the study. But the prepubertal children who received extra calcium 
showed greater overall gains, including statistically significant gains in the forearm 
and spine. There was no difference in response to the calcium supplement between 
the boys and girls in the study. 

This finding highlights the importance of adequate calcium intake in children. Be- 
cause bone loss typically begins around 35, even small changes in peak bone mass in 
the population may contribute to reductions in the fracture rates seen in older men 
and women. 

TO DRIVE OR NOT TO DRIVE? NEW RESEARCH DEFINES RISK, SHOWS HOW OLDER DRIVERS' 

SKILLS CAN BE IMPROVED 

Each year many older Americans and their families have to ask whether — in the 
face of advancing age, disability, vision loss, and attention problems or Alzheimer's 
disease — the license to drive should be limited or even taken away. With more and 
more older drivers on the road as the population ages, questions about their safety 
become more urgent. 

Scientists are beginning to find some answers. Driver accidents analyzed by NIA 
scientists show that, contrary to popular stereotypes, crash rates for older drivers 
fell during the 1980's. However, the rate of deaths increased significantly, suggest- 
ing older drivers may be particularly vulnerable when crashes do occur. 



186 



These findings were reported by NIA scientists at a meeting in Bethesda, Mary- 
land, cosponsored by NIA, the National Highway Traffic Safety Administration, the I 
Federal Highway Administration, and the Centers for Disease Control. The scien- 
tists focused on identifying what additional research is needed to improve the safety 
and mobility of older drivers. They specifically emphasized the older drivers' func- 
tional abilities. Suggestions were made on ways to better understand accident risk 
among older people, how deaths among this segment of the population could be re- 
duced, and ways to test and improve driving skills. 

The number of older drivers rose rapidly during the 1980's and this increase was 
most marked among drivers over 70. These changes brought with them a sharp in- 
crease in older people who were killed when driving a car. In fact, while driving 
fatalities decreased during the 1980's fatalities among drivers over 65 increased by 
43 percent. 

Despite these fatality statistics, there is no support for the view that older drivers 
are an undue risk to others on the highway. Crash rates (accidents per 100 drivers) 
for people 65 and older fell significantly from 1980 to 1989. The increase in fatalities 
suggests rather that older drivers may be at greater risk of dying when involved in 
a crash. So the concern is for the risk of injury to the older person. 

The freedom that driving means for older people is also of concern, especially for 
the increasing population in the suburbs and rural areas. Losing a license to drive 
can mean ending the independence to visit friends, to go grocery shopping, or to see 
the doctor. The decision of" whether or not to continue driving is a difficult one for 
older people and their families. 

NIA meeting participants recommended a balanced approach to address the prob- 
lems facing older drivers. While scientists must find ways to identify the driving 
limitations experience by older people, cars and highways also need to be made 
safer. Meanwhile, licensing programs should not needlessly deny or restrict older 
drivers. 

RESEARCHERS ENCOURAGE GREATER USE OF VACCINE FOR PNEUMOCOCCAL INFECTIONS 

NIA grantees have found convincing evidence that a pneumococcal vaccine, avail- 
able in the United States since 1977, should be used more widely to prevent pneu- 
monia in high-risk groups, such as older adults. 

Dr. Eugene D. Shapiro at the Yale University School of Medicine in New Haven, 
Connecticut, and his colleagues have been studying the polyvalent pneumococcal 
vaccine, which prevents infection with Streptococcus pneumoniae, the most common 
cause of bacterial pneumonia. The researchers learned the vaccine was 61 percent 
effective in people with normal immune systems. 

This 6-year study included 2,108 adult patients in 11 hospitals throughout Con- 
necticut. The pneumococcal vaccine was given to 1,054 of the participants. After- j 
ward, scientists compared the rate of vaccination in people who developed serious 
pneumococcal infection against the rate of un vaccinated controls. 

The pneumococcal vaccine is currently recommended by the Public Health Serv- 
ice for everyone over age 65, although only about 20 percent of older Americans \ 
have been vaccinated. It is most effective when received before age 65 rather than 
later, and experts are now considering whether the age for this universal recom- 
mendation should be dropped to 55. 

The groups at highest risk of developing an infection are older adults, individuals 
with a chronic illness (such as heart disease or diabetes), and people with a weak 
immune system (such as resulting from kidney disease, some cancers, HIV infection, 
and other conditions). These groups are more likely to develop pneumonia than 
others, and their illness is more likely to be life-threatening. 

Dr. Shapiro and his colleagues believe their study provides the evidence that im- 
munizations are valuable for preventing pneumonia. Although widespread vaccina- 
tion will not totally eliminate the disease, it will significantly reduce the incidence. 
Meanwhile, work is under way on improving the vaccine's effectiveness. 

DIABETES AND AGING 

NIA studies the biological mechanisms underlying diabetes as well as risk factors 
for the disease, which is about 10 times as prevalent among older people as in I 
younger adults. Recent NIA findings show that fasting glucose levels as low as 107- 
111 mg/dl in older people indicate a risk for developing diabetes. Researchers at the 
NIA's Gerontology Research Center in Baltimore, Maryland, examined 25 years of 
data on diabetes risk factors from its Baltimore Longitudinal Study of Aging 
(BLSA). The BLSA is an ongoing study involving more than a thousand men and 
women from age 20 to over 90. They found that fasting glucose levels as low as 103- 



187 



106 mg/dl in men 28-59 years of age and 107-111 mg/dl in men 60-96 years of age 
carry significantly increased risk for the future development of diabetes. These 
levels are considerably lower than those previously considered to place an individ- 
ual at risk. 

According to the BLSA data, increasing obesity and abdominal fat explain much 
of the higher risk for diabetes that come with age. Other studies have shown that 
diet plus moderate exercise can reduce these risks. How exercise lowers risk was 
demonstrated by recent, NIA-sponsored research in which exercise training im- 
proved glucose tolerance and insulin sensitivity. The improvements were linked to 
increases in lean body mass, reduced fat mass, and higher glucose disposal rates. 

In studying the mechanisms of age-related insulin resistance, another NIA grant- 
ee found no difference in number of insulin receptors between young and old rats. 
Insulin receptors from older rats, however, showed significantly lower levels for 
both the enzyme tyrosine kinase and autophosphorylation, which are needed by in- 
sulin to stimulate glucose transport into cells. These findings suggest that such defi- 
cits may be major factors in age-related insulin resistance. 

ARTHRITIS AND AGING 

Arthritis is an area of special importance to the institute since it affects over 18 
million individuals over age 60 and is the number one cause of disability for older 
people. 

Osteoarthritis, the most common form of arthritis, is the focus of recent studies 
conducted by Dr. Marc C. Hochberg and colleagues at the University of Maryland 
School of Medicine and Dr. Jordan D. Tobin and associates at' NLA's intramural pro- 
gram at the Gerontology Research Center. These scientists analyzed cross-sectional 
longitudinal data from the Baltimore Longitudinal Study of Aging to examine risk 
factors for hand arthritis in both women and men. They evaluated the role of age, 
obesity, body composition, bone mass, muscle mass, and muscle strength as risk fac- 
tors for hand arthritis. Body mass index, waist-to-hip ratio, arm and shoulder skin- 
fold thicknesses, bone mineral density, and grip strength were measured. Changes 
in hand osteoarthritis were identified on X-ray obtained as part of the longitudinal 
study's evaluation of participants. 

The data from these studies failed to demonstrate causal associations between 
obesity, body fat distribution, body composition, bone mass, forearm muscle mass, or 
grip strength with either the presence or progression of hand osteoarthritis among 
participants. However, hand arthritis increased as participants aged. 

OLDER RURAL POPULATIONS 

In light of the rapidly increasing costs for health care, NIA places a high priority 
on research that examines access to health care services for older people living in 
rural areas of the United States. AD in rural populations is the focus of a major 
research program at NIA. Much of what is known about AD comes from studies of 
people who seek care in university medical schools, such as the NIA-funded Alzhei- 
mer's Disease Centers across the country. Rural areas, and particularly the Appa- 
lachian mountain region, are of special interest because many of the residents expe- 
rience poverty, malnutrition, an inferior education, and dangerous work environ- 
ments. They are often injured or develop illnesses associated with these work places; 
exposed to environmental toxins in the agricultural and mining industries; and re- 
ceive infrequent, inadequate health care. 

To extend the services of Alzheimer's Disease Centers, NIA recently established 
26 Satellite Diagnostic and Treatment Clinics. These clinics will encourage greater 
participation at existing centers by people who need services but are unable to gain 
access because of their living conditions. Researchers believe these clinics will 
produce greater heterogeneity among participants, which in turn will result in more 
generalizable research findings. 

In a separate study on AD in rural populations, NIA researchers at the Universi- 
ty of West Virginia have been analyzing prevalence of AD among poor, older people 
living in Morgan, Marshall, and Tucker counties. Results from this ongoing project 
will add to our basic knowledge about the disease and can aid State policymakers in 
identifying those older residents in greatest need of resources. 

The Center on Aging and Health in Rural America is a large multidisciplinary 
study evaluating the effects of socioeconomic and demographic characteristics on 
the health care services received by older people in rural communities. Researchers 
recently found that older people in rural areas are poorer than their urban counter- 
parts, and this difference increases with age. After demographic variables (such as 
age, sex, race, and education) were matched between the rural and urban groups, 



65-505 - 93 - 7 



188 



the investigators were able to link the rural group's lower socioeconomic level to 
preretirement employment conditions and to the lower pay scales prevalent in rural 
communities. It will be important to determine if the lower cost of living in rural 
settings is significant enough to offset the reduced income, particularly in terms of 
gaining access to needed health services. 

OLDER MINORITY POPULATIONS 

NIA supports a broad range of research related to life expectancy, health, envi- 
ronmental influences, social networks, interventions, and biomedical characteristics 
targeted to ethnic minorities. NIA has worked aggressively to enhance existing bio- 
medical, clinical, and behavioral research on minority aging and is committed to in- 
creasing the racial and ethnic diversity of its investigators. 

Institute funding for research efforts relevant to ethnic minorities has nearly dou- 
bled since 1991. In 1992, approximately $18 million was obligated to expand existing 
programs as well as start new initiatives. Regarding the development of minority 
scientists, NIA awarded over $2 million in supplemental funding to support under- 
represented minority researchers, including supplements to renowned MERIT 
grantees. As one other example of institute support for minority scientists, approxi- 
mately $900,000 in funding was used by the NIH Minority Biomedical Research 
Support Program. 

Highlighting NIA-sponsored research on minority aging, several major new initia- 
tives were launched in 1992. These included approximately $2 million in awards fo- 
cused on older Hispanic populations, $1.9 million for research on the long-term care 
needs of ethnic minority populations, and $750,000 for educational outreach pro- 
grams on AD. Many of the institute's fact sheets about aging — known as Age 
Pages — have been translated into Spanish, and new dissemination efforts geared 
toward older Hispanic communities are presently under way. The institute is also 
expanding its efforts to increase the representation of African-American men and 
women in its intramural program, the Baltimore Longitudinal Study of Aging, 
which is a landmark study on human aging. NIA also sponsors the Summer Insti- 
tute in Research on Minority Aging, a week-long conference held yearly that focuses 
on ethnic minority aging. The Summer Institute provides the opportunity for begin- 
ning researchers, university faculty members, and institute staff to discuss topics re- 
lated to health, race, and aging. 

AIDS AND OLDER AMERICANS 

Immune function normally decreases with age, but it declines more quickly in 
older AIDS patients, who become sick and die sooner than their younger counter- 
parts. People with AIDS who are age 50 and above account for about 10 percent of 
all AIDS patients in the United States. Thus, NIA researchers continue to explore 
the effects of age on HIV infection and the immune response to HIV. 

In the first category, exploring the effects of age on HIV infection, recent labora- 
tory work has shown that it takes longer for older people to produce new T-cells 
following trauma. This finding suggests that the net sum of circulating T-cells in an 
HIV-infected person depends not only on how many are destroyed but also on how 
quickly new T-cells enter the system. In older AIDS patients, the study suggests, the 
rate of entry is probably slower than in younger patients. 

In the second category, immune response to HIV, investigators at NIA have also 
learned more about the basic biology of the infection. A key finding is that while 
antibodies to certain HIV antigens decline as the infection progresses, other anti- 
bodies — those to the so-called envelope antigens — remain at high levels. Envelope 
antigens are also found at high levels in the serum of AIDS patients, and the anti- 
bodies bind to them, creating large numbers of antigen-antibody complexes. These 
toxic combinations are usually dealt with by immune system cells called macro- 
phages, but in AIDS patients their sheer numbers appear to overwhelm the body's 
defenses, preventing them from dealing with other assaults, such as an invasion of 
bacteria. This appears to be one reason that AIDS patients are highly susceptible to 
infection. 

Other recent findings show that certain illegal drugs can influence sectors of the 
immune system. Researchers sponsored by NIA and the National Institute on Drug 
Abuse found that amyl nitrate can inhibit natural killer cell activity and cocaine 
can cause a decline in antibody production in laboratory tests. 



189 



RESEARCH ADVANCES ON AGING SUPPORTED AND CONDUCTED BY 
OTHER NIH INSTITUTES 

National Cancer Institute 

More than one-half of all cancers are diagnosed in people over 65 years of age. 
The National Cancer Institute (NCI) is using the full range of its resources to ad- 
dress this important problem. For example, all NCI-supported clinical trials are re- 
viewed to ensure that older patients are not arbitrarily excluded from participation. 
Eight treatment trials focus primarily on cancers in older patients. In addition, 
trials for breast cancer in post-menopausal women and for prostate cancer have a 
large percentage of older people. 

The NCI efforts include information and awareness campaigns, studies of the ef- 
fects of lifestyle practices on health in older Americans, and basic research on the 
aging process. An NCI educational initiative provides information on early detection 
tests and treatment choices. During 1992, NCI started a major new clinical trial to 
look at methods of detecting cancers of the prostate, lung, colon and rectum, and 
ovary. The study is designed to see if screening tests such as flexible sigmoidoscopy 
for colon cancer, chest X-rays for lung cancer, and pelvic exam, transvaginal ultra- 
sound and CA 125 tests for ovarian cancer can reduce cancer mortality in older 
Americans. This large trial will also define the positive predictive value of screening 
tools such as prostate specific antigen (PSA) for early detection of prostate cancer. 
About 74,000 women and 74,000 men ages 60-74 will participate. 

The National Center for Nursing Research and NIA have joined NCI in a 3-year 
research initiative to enhance care for older women with cancer. This program fo- 
cuses on identifying factors that influence delays in diagnosis, evaluation of the 
extent of disease, and referrals for supportive care and rehabilitation for breast 
cancer patients who are at least 65 years old. Investigators are exploring what influ- 
ences treatment decisions, as well as access to and availability of cancer care. 

National Heart, Lung, and Blood Institute 

The National Heart, Lung, and Blood Institute (NHLBI) supports a number of 
large, population-based studies related to cardiovascular disease (CVD) in older 
people. The past year has brought new findings that extend our understanding of 
CVD risk in that age group. For instance, the long-running Framingham Heart 
study recently reported data from echocardiography measurements of 1,159 partici- 
pants. The findings demonstrated a greater than two-fold increased risk of stroke in 
participants with calcification of the mitral valve annular, after adjustment for 
other stroke risk factors such as age, sex, systolic blood pressure, diabetes, cigarette 
smoking, atrial fibrillation, coronary heart disease, and congestive heart failure. 
Even when participants with coronary heart disease or congestive heart failure 
were excluded from analysis, those with mitral annular calcification still had twice 
the risk of stroke as those without. 

Following the recent demonstration in the Systolic Hypertension in the Elderly 
Program (SHEP) that treatment of isolated systolic hypertension (ISH) reduces risk 
of stroke in older people, cross-sectional data from the Cardiovascular Health Study 
were analyzed to determine the association between ISH and noninvasive measures 
of subclinical disease. Among 2,189 persons age 65 and older, ISH was strongly asso- 
ciated with increased left ventricular mass, a known risk factor for CVD, and with 
increased intima-media thickness of the carotid artery. These findings underscore 
the importance of diagnosing and treating ISH, a common condition among older 
people. 

National Institute of Dental Research 

The National Institute of Dental Research (NIDR) gives high priority to the oral 
health of older Americans. Saliva plays many important roles in the mouth, particu- 
larly in oral immunity and digestion. Saliva contains special immune components 
which limit the growth of harmful bacteria that cause tooth decay and other oral 
infections. Saliva also lubricates the mouth's soft tissues, making speaking and 
chewing easier, and it assists digestion by providing enzymes that break down food. 
Because of saliva's importance to oral health throughout life, NIDR scientists exam- 
ined salivary function in a 10-year study of healthy older Americans. Expanding on 
a previous finding that saliva output does not diminish with age, investigators this 
year showed that important components in saliva collected from parotid glands, one 
of the three major pairs of salivary glands, do not alter over time. They concluded 
that salivary composition remains unchanged as individuals grow older. 



190 



In another study, NIDR grantees are exploring whether a combination of peri- 
odontal disease, dry mouth, and swallowing disorders places older people at in- 
creased risk for aspiration pneumonia, a leading cause of death among people over 
65. This form of pneumonia results when bacteria-infected saliva is aspirated into 
the lungs. In a study of 450 older people (ages 58 to 100), researchers found that 
almost one-third took medications that cause dry mouth, one of the suspected risk 
factors. The scientists are now investigating whether periodontal disease is the 
source of the bacterial infection that causes aspiration pneumonia and whether 
swallowing disorders promote the influx of bacteria into the lungs. 

National Institute of Diabetes and Digestive and Kidney Diseases 

Osteoporosis is a major public health issue that affects large numbers of postmen- 
opausal women. As the lead institute for endocrine and nutrition research, the Na- 
tional Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) conducts 
and supports research on the multiple ways vitamin D and its receptor stimulate 
bone formation and resorption. 

In earlier research supported by NIDDK, scientists verified that vitamin D was 
targeted to cells in the intestines, bone, and kidneys. However, they also found the 
vitamin D receptor in unexpected places, such as in breast epithelial cells, in the 
ovaries, in pancreatic islet cells, in certain skin cells, and in some malignant cells, 
leading them to consider whether vitamin D did more than raise the level of calci- 
um and phosphorus in blood to form bone. 

Using techniques of molecular biology, these scientists have now delineated the 
structure and function of the vitamin D receptor. They have discovered that vitamin 
D and its receptor not only synthesize bone proteins and stimulate the body's use of 
calcium and phosphorus to build bone, but that they also play a second important 
role in stimulating and signaling the bone cells responsible for bone remodeling. 

With this knowledge, researchers are now in a position to develop analogs for vi- 
tamin D as a treatment for osteoporosis, and to explore the use of vitamin D com- 
pounds to treat some types of cancer and skin disease such as psoriasis. 

National Institute of Neurological Disorders and Stroke 

The National Institute of Neurological Disorders and Stroke (NINDS) is the lead 
institute for research on a number of nervous system disorders — such as stroke and 
Parkinson's disease — that occur with greater frequency in older people. The insti- 
tute also conducts and supports research on a number of other diseases that occur 
more commonly in older people such as AD. 

SCIENTISTS INVESTIGATE PARKINSON'S DISEASE 

Parkinson's disease — characterized by tremors, rigidity, and difficulty initiating 
movement-adversely affects the quality of life for more than half a million people in 
the United States. Even simple tasks, such as holding a spoon or rising from a chair, 
can become impossible for Parkinson's patients. The disease occurs as a result of a 
loss of brain cells that produce dopamine, a chemical that carries signals from one 
nerve cell to another. While many advances have been made in treating the symp- 
toms of Parkinson's disease, its underlying cause remains a mystery. This year, sig- 
nificant findings by NINDS investigators are yielding intriguing new clues to the 
disease. 

In the last decade, the chemical MPTP (l-methyl-4-phenyl-l,2,3,6-tetrahydropyri- 
dine) has become a highly significant tool for research on Parkinson's disease. 
MPTP becomes transformed in the body into a toxic chemical that selectively de- 
stroys dopamine neurons in the substantia nigra, part of the basal ganglia at the 
center of the brain. This destruction results in a paralysis that faithfully mimics 
Parkinson's disease, allowing researchers to create a useful animal model of the dis- 
ease and test possible therapeutic drugs. The high degree to which MPTP replicates 
the natural pathology of Parkinson's disease suggests that the disease itself may be 
the result of an internal or external neurotoxin that resembles the chemically 
transformed MPTP. This year, scientists funded by the NINDS suggested that a 
class of MPTP-like compounds called N-methylated beta-carbolines could be capable 
of producing Parkinson's disease. 

Scientists are also looking for the cause of Parkinson's disease in the cell struc- 
tures that carry dopamine in and out of the synapse between cells. One group found 
an age-related decrease in dopamine transporter in the area of the brain that is 
damaged in Parkinson's disease. 



191 



Since the 1960's, L-dopa has been the major drug for relieving the symptoms of 
Parkinson's disease. Clinicians have found, however, that the effectiveness of L-dopa 
fluctuates over the course of therapy. This year, one group of NINDS-supported in- 
vestigators found evidence that this clinical "on-off" phenomenon is the result of 
desensitization of the dopamine receptors in the brain. This provides the basis for 
research aimed at affecting this desensitization process and ameliorating the "on- 
off clinical phenomenon. 

One new avenue of research on treatments for Parkinson's disease focuses on a 
method for delivering dopamine to critical areas in the brain. NINDS-supported in- 
vestigators, using an animal model of the disease, implanted tiny dopamine-contain- 
ing particles into brain regions affected by the disease. The investigators found that 
such implants can partially ameliorate the movement problems found in these ani- 
mals. The results suggest that similar techniques may work for people with Parkin- 
son's disease. 

SCIENTISTS STUDY RAPID TREATMENT FOR STROKE 

Stroke represents the third most common cause of death in the United States, 
and the disease results in physical and psychological disability far more often than 
death. This year, NINDS supported studies of tissue plasminogen activator (tPA), a 
compound that breaks up blood clots in the brain and might stop brain injury early 
in the course of a stroke. In preliminary studies, the scientists found that patients 
with acute stroke could be treated with tPA and that success might be expected if 
the drug is given within 90 minutes of the stroke's onset. These results lead to the 
need for a randomized clinical trial of the drug in humans. 

National Institute of Allergy and Infectious Diseases 

The broad range of basic research supported by the National Institute of Allergy 
and Infectious Diseases (NIAID) in the prevention, diagnosis, and treatment of infec- 
tious diseases is an important area of focus in studying the problems of older people. 
Respiratory infections, such as pneumonia, are often more serious in this population 
than in other age groups. In addition, an increasing number of people are develop- 
ing asthma later in life. Chlamydia pneumoniae is emerging as an important cause 
of respiratory conditions, including pneumonia and asthma. 

The difficulty of diagnosing C. pneumoniae infection by standard tests such as se- 
rology and culture may delay infection. Recently, NIAID intramural scientists have 
experimented with using a laboratory test called polymerase chain reaction-enzyme 
immunosorbent assay (PCR-EIA) to detect chlamydial antigen. The PCR technique 
is a method of amplifying an organism's DNA so that minute quantities can be de- 
tected. The researchers used this technique on 132 samples from immunocompro- 
mised patients with pneumonia that had been negative using the culture technique 
to detect the organism. In the PCR-EIA test, however, 9.8 percent of the culture- 
negative samples were positive for C. pneumoniae. The PCR-EIA technique, which 
is more sensitive than others, could be an important tool in identifying this difficult- 
to-isolate bacterium. 

National Eye Institute 

Today, there are over 32 million Americans age 65 and older. By the year 2030, 
this figure will more than double to nearly 66 million Americans. With more older 
people in our society, more Americans than ever will enter the Nation's health care 
system with eye diseases such as cataract, age-related macular degeneration (AMD), 
and glaucoma. A major goal of the National Eye Institute (NED is to find ways of 
reducing age-related vision loss that can reduce quality of life. 

An important research challenge is to differentiate the abnormalities underlying 
age-related eye disease from the eye's natural aging process. It a better understand- 
ing of these processes can be obtained, it may be possible to develop improved pre- 
vention and treatment strategies for these diseases. To promote research in this 
area, the NEI has launched the Age-Related Eye Diseases Study (AREDS), a major 
multicenter clinical project in which researchers will document the ocular aging 
process in over 4,600 older Americans. 

Another challenge is to evaluate whether vitamin and mineral supplements slow 
the development or progression of cataract and AMD. Some research data suggest 
that people at risk for cataract and AMD can benefit from vitamin and mineral sup- 
plements, since these may activate key enzyme systems or serve as antioxidants. 
The NEI has recently established a new component of the AREDS to evaluate vita- 
min and mineral supplementation. Because this area of the study will be conducted 



192 



as a large randomized clinical trial, AREDS should offer the most definitive infor- 
mation to date on this important therapeutic question. 

National Institute of Environmental and Health Sciences 

The National Institute of Environmental and Health Sciences (NIEHS) places a 
high priority on research investigating the environmental contribution of certain 
diseases or conditions that commonly affect older people, basic research on the 
mechanisms of aging, and the effect of environmental agents on the aging process. 

GENE MAPPING AND SEQUENCING RESEARCH 

NIEHS intramural scientists have an ongoing program to map and sequence 
genes that regulate the aging process, and genes that predispose individuals for can- 
cers that affect older people such as breast and prostate cancer. Discovering, map- 
ping, and sequencing these genes will enable physicians to identify individuals who 
are at risk of developing diseases as they age, and to develop strategies to block the 
expression of undesirable genes. 

THE EFFECTS OF HAZARDOUS ENVIRONMENTAL AGENTS ON THE AGED 

As people age they become more sensitive to environmental agents, their organs 
and systems become more susceptible to damage from exposure, and their ability to 
recover from harmful environmental exposure is impaired. Exposure to certain 
agents may hasten or exacerbate the aging process. NIEHS-supported researchers, 
using animal models and human epidemiologic studies, determine how certain types 
of exposure — such as to air pollution, ultraviolet light, and heavy metals — affects 
people differently as they age. These study results are used to develop strategies to 
prevent exposure and illness, and to bring about regulations to protect those popula- 
tions who are more susceptible. 

National Institute of Arthritis and Musculoskeletal and Skin Diseases 

Many of the disease conditions under the aegis of the National Institute of Arthri- 
tis and Musculoskeletal and Skin Diseases (NIAMS) are associated with aging. 
These include certain bone diseases such as osteoporosis and Paget's disease, joint 
diseases such as osteoarthritis, degenerative back diseases, and skin diseases such as 
pemphigus. 

More than 1.5 million Americans each year have fractures of the hip, wrists, and 
spine due to osteoporosis. NIAMS scientists, studying bone mineral density in the 
wrists and hips of 1,150 older men and women, found that men had significantly 
higher bone mass than did women. Other NIAMS researchers found that moderate 
weight-bearing exercise increased bone mineral density in the lower spine of both 
men and women. They concluded that weight-bearing exercise is vital to prevent ex- 
cessive bone loss in older people. 

Osteoarthritis (OA) affects an estimated 16 million Americans and may cause dis- 
ease in the knees, hips, and spine. In separate studies, NIAMS researchers found 
that the risk of OA in the knee can be significantly reduced by weight loss (in 
women) or by a program of supervised fitness walking. OA causes considerable dis- 
ability and accounts for most of the total knee replacements done in the United 
States annually. 

Paget's disease affects more than 3 million older Americans. It causes increased 
bone formation in one or more bones of the skull, pelvis, hips, and knees. Research- 
ers have found that calcitonin may be a valuable treatment for patients with ad- 
vanced stages of the disease. 

National Institute of Deafness and Other Communication Disorders 

The National Institute of Deafness and Other Communication Disorders (NIDCD) 
supports and conducts research and research training in hearing, balance, smell, 
taste, voice, speech, and language. The physiological changes that occur with normal 
aging may affect each of the NIDCD's seven areas of interest. In addition, certain 
diseases and disorders associated with aging may affect the ability to communicate. 

NIDCD-supported scientists studying presbycusis, or age related hearing loss, 
tested whether inner ear pigment protects the ear from degeneration and subse- 
quent hearing loss. While it was thought that loss of pigment in the inner ear with 
age contributes to hearing loss, these investigators concluded that age-related inner 
ear degeneration does not appear to be related to inner ear pigment. 



193 



Parkinson's disease is usually associated with people in older age groups. It is pos- 
sible that some forms of this disease may be caused by an environmental toxin that 
enters the body through the olfactory nerve which transmits smell impulses from 
the nose to the brain. A recent NIDCD-supported study found that persons with 
Parkinson's disease caused by injections of the street drug MPTP have a normal 
sense of smell, whereas those with the disease from unknown causes have a reduced 
sense of smell. This supports the theory that some forms of Parkinson's disease may 
be caused by environmental toxins that enter the brain through the olfactory nerve. 

National Institute of Mental Health 

One focus of research at the National Institute of Mental Health (NIMH) is to 
better understand the etiology, course, and treatment of the major mental disorders 
of late life. At least 8 percent of the older population are affected by AD and other 
dementias; 20 percent suffer from anxiety disorders, including phobic disorders; and 
nearly 1 percent suffer from schizophrenia. Delirium, sleep disorders, and personali- 
ty disorders are also common among older people. Nearly 40 percent of geriatric pa- 
tients having major depression also meet criteria for an anxiety disorder. As many 
as 30 percent of dementia patients suffer from major depression and may exhibit 
symptoms of agitation, paranoia, hallucinations, and sleep disturbance. Among frail 
older people with multiple coexisting medical illnesses, "failure to thrive" has been 
associated with psychiatric symptoms. By one estimate, only about 10 percent of 
older people in need of psychiatric treatment ever receive it. 

Data from NIMH-supported studies suggest that many disorders with late life 
onset appear to have different clinical, neurobiological, cognitive, and psychosocial 
features; and they respond differently to treatment than early onset forms of the 
disorders. For example, brain imaging studies have found differences in certain 
brain structures of older psychotic depressed patients. Researchers are exploring the 
hypothesis that geriatric depression may have a different etiology and pathogenesis, 
including brain changes induced by neurological diseases or aging. These results 
suggest that findings based on samples of young adults may not apply to older 
people. 

Depressive illness in the older population continues to be a serious public health 
concern. In the NIH Consensus Development Conference on Diagnosis and Treat- 
ment of Depression in Late Life, cosponsored by NIMH, it was reported that nearly 
5 million individuals age 65 and over have serious, persistent symptoms of depres- 
sion and over 1 million suffer from major depression. Several NIMH studies demon- 
strate that psychopharmacological approaches and electroconvulsive therapy are ef- 
fective in treating acute depressive episodes, either alone or in combination with 
psychosocial approaches. 

New studies using imaging techniques and pharmacologic probes suggest that 
geriatric patients with delusional depression may represent a distinct subtype. Pa- 
tients with delusional depression were found to have a trend toward chronicity or 
partial recovery, compared to nondelusional depression; but once recovered, delu- 
sional patients were less likely to relapse. Researchers also found an association be- 
tween hearing loss and delusional depression; moreover, computerized tomography 
scans show differences between patients with delusional and nondelusional depres- 
sion. 

It is well documented that older people have the highest suicide rate. White men 
over 65 have a suicide rate more than double that of adolescents. With increasing 
age, suicide victims use more effective and lethal means to take their lives, such as 
firearms. Thus, older people have a much lower ratio of attempted to completed sui- 
cides. NIMH research (based on psychological autopsy data) shows that a profile for 
late life suicide is distinguishable from suicide in other age groups. This profile uses 
demographic, behavioral, and psychological factors to support the following conclu- 
sions: suicide in older people is strongly associated with affective disorder (depres- 
sion) with late onset; depression in older suicide victims is primarily unipolar and 
less often associated with psychosis or active substance abuse; and suicide in older 
people is frequently associated with physical illness or loss. About 70 percent of 
older suicide victims had been seen by their primary care physician in the month 
prior to the suicide, but in no case was depression recognized or treated. 

Between 30 and 50 percent of older people suffer from chronic sleep disturbance, a 
condition often leading to problems with use of sleeping pills (hypnotic medications), 
reduced quality of life, and increased morbidity and mortality. Hypnotic drugs may 
worsen breathing problems during sleep and produce daytime carryover effects such 
as sleepiness, falling and subsequent fractures, cognitive impairment, and forgetful- 
ness. Clinical trials have demonstrated that cognitive-behavioral therapy and light 



194 



therapy may effectively relieve sleep disturbances in older people. Moreover, prelim- 
inary evidence indicates that increased aerobic fitness can improve the quality of 
sleep. Findings from the trials of light therapy are particularly encouraging because 
of the potential use of this strategy with cognitively impaired and depressed people. 
Researchers are now investigating the use of these therapies for long-term mainte- 
nance, as well as their effectiveness among different older populations. They have 
demonstrated that acute depression in late life is associated with profound and spe- 
cific changes in the physiological organization and intensity of sleep, and that tricy- 
clic antidepressants can alter sleep (as measured by electroencephalogram) in de- 
pressed patients. 

An NIMH-NIA longitudinal study will soon examine the reciprocal effects of spe- 
cial environment and psychological functioning in older people. Researchers have lo- 
cated and are resurveying most of the 1974 respondents from a 1964-74 study. The 
study had demonstrated that the complexity of social environments (i.e., on the job 
or at home) has a positive effect on cognitive functioning. Regardless of age, partici- 
pants engaged in more substantively complex and self-directed work over the 1964- 
74 decade were more likely to improve their cognitive functioning than those en- 
gaged in less complex work. 

NIMH scientists are also studying Parkinson's disease. The disease is caused by 
degeneration in a small group of dopamine-containing neurons. These neurons are 
crucial to the regulation of movement, eating and drinking, and other behaviors 
that are deficient in persons with Parkinson's disease. Researchers have performed 
grafts of normal tissues in rats and now in the rhesus monkey. Graft survival is 
erratic; however, in animals showing the greatest success, the behavioral response 
produced by the graft has lasted one year. An instrument that facilitates grafting 
was developed and a patent awarded. 

AD progresses gradually over periods of up to 20 years, and initial symptoms usu- 
ally include mild memory loss. As the disease progresses, patients present more pro- 
nounced cognitive impairment, personality changes, disorientation, and wandering 
behavior. NIMH scientists have identified a spinal fluid protein (alpha-2-haptoglo- 
bin) that is elevated in AD patients, and which may be useful as a diagnostic 
marker for the disease. 

NIMH research has shown that many brain changes caused by AD are seen in the 
normal brains of older people. The question then is whether a key difference exists 
in Alzheimer's brains. One working theory many scientists are using is that in dis- 
eased brains there is an exaggeration of the normal aging processes. Recent re- 
search has shown that certain brain chemicals, acetylcholine and somatostatin, 
which control communication between nerve cells involved in cognitive and memory 
functioning are profoundly diminished in Alzheimer's brains. Research efforts are 
focused on learning as much as possible about how these substances work and how 
they interact with each other. 

National Institute on Alcohol Abuse and Alcoholism 

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) conducts and 
supports biomedical and behavioral research on the causes, consequences, treat- 
ment, and prevention of alcohol-related problems. 

One of NIAAA's alcohol research centers is devoted entirely to the study of alco- 
hol and aging. At the University of Michigan center, researchers are examining 
medical effects of alcohol use, age-related changes in alcohol sensitivity, and strate- 
gies to foster identification and treatment of alcoholism in older adults. 

Several NIAAA epidemiological studies are underway to derive information on 
drinking patterns and problems among older drinkers, especially women, and the 
relationships between alcohol consumption and health problems such as hyperten- 
sion and heart disease, and cirrhosis morbidity and mortality. 

Using noninvasive imaging techniques in persons with alcoholism, researchers 
have found that reductions in both whole brain gray and subcortical white matter 
accelerate with age. Research in both humans and animals has shown that older 
individuals have increased sensitivity to the acute effects of alcohol, as measured by 
physiological responses and motor impairment. Results from some cognitive func- 
tion studies further suggest that alcoholism and aging may have a compound effect 
on cognition — so that the aging brain may be at increased risk from deleterious al- 
cohol effects. 

National Center for Research Resources 

Resource centers and other funding mechanisms provided by the National Center 
for Research Resources (NCRR) support a variety of studies on aging, including the 



195 



development of an animal model for postmenopausal bone loss. Scientists at More- 
house School of Medicine have found that an analogue of the reproductive hormone 
gonadotropin-releasing hormone (GnRH) can induce early and reversible menopause 
in rhesus monkeys. These animals not only serve as a model for human menopause, 
but also can be used to study progression and treatment of postmenopausal bone 
loss. 

In collaboration with investigators at the Yerkes Regional Primate Research 
Center in Atlanta, the scientists at Morehouse recently discovered that growth hor- 
mone administration helps to preserve bone mass in these animals. A group of 
GnRH agonist-treated monkeys lost about 12 percent of their bone mass, whereas 
animals treated with GnRH agonist plus growth hormone showed no significant 
bone loss. These findings indicate that growth hormone therapy may have potential 
for reducing bone loss in menopausal women and in women who take GnRH agon- 
ists to treat endometriosis and other conditions. The scientists are now investigating 
how growth hormone and other compounds help to interrupt the progression of 
bone loss. 

National Center for Nursing Research 

The National Center for Nursing Research (NCNR) focuses on long-term care 
strategies for older people to help them maintain optimal health status, the highest 
functional ability, and the best quality of life possible. 

A widespreasd impediment to this goal is confusion, which affects an estimated 50 
percent of hospitalized older patients. It increases morbidity, mortality, and compli- 
cations such as dehydration and falls. NCNR-funded studies of assessment tools and 
intervention strategies are determining the nature of confusion, at what point it 
occurs, and what nurses and others can do to prevent or modify it. 

One study has tested a new evaluation scale to identify those at risk for confusion 
and those already showing symptoms. It can be scored by nurses at the bedside with 
little stress to patients; at the same time, it is a more sensitive measure of early or 
mild cognitive disturbances than other mental status tests. Using this scale, re- 
searchers have identified three patterns of confusion: chronic or environmentally in- 
duced, physiological, and metabolic. Pattern-specific nursing interventions are cur- 
rently being developed and tested to reduce the incidence of confusion and improve 
patient functioning. This and similar studies will help nurses distinguish among 
types and causes of confusion, recognize patients at risk who need preventive care, 
and modify existing confusion using interventions tailored to the cause. 

OUTLOOK 

The breadth of scientific findings in this report demonstrates NIH's success in im- 
plementing its research agenda. These achievements by NIH scientists are already 
beginning to provide the information needed by doctors to treat their older patients. 

The various NIH programs including NIA, which is the lead federal agency re- 
sponsible for conducting research on the health of older adults, are achieving rapid 
progress on several fronts. Scientists are clarifying the differences between normal 
aging processes and disease states; they are identifying the basic biological mecha- 
nisms that control aging; and they are training geriatricians as research scientists 
and physicians. With an increasing body of scientific knowledge and more doctors 
tained in geriatrics, older Americans are beginning to receive more effective health 
care. As research advances continue to become available, long-range goals will also 
be realized: older Americans can expect to stay healthy for a greater part of their 
later years, and the Nation will have information needed to control health care 
costs. 



196 



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