Perspectives on Aging and Societal Issues

Remarks for the White House Forum: Technologies for Successful Aging

October 4, 2000
Ruth Kirschstein, M.D.
Principal Deputy Director
National Institutes of Health

Let me begin with a personal note — In this country, when I was born, life expectancy was not yet age 65.  I have lived past that age by several years now, and I am glad of this, for many reasons.  First, it has enabled me to continue my pursuit of medical science.  And, second, reaching age 65 is no longer remarkable.  Today, in the United States, about one person in eight is at least 65 years old.

Our longer lives have a great deal to do with knowledge gained through medicine and science. Public health measures, like universal vaccination programs, have reduced many deadly infectious diseases, including polio, to nearly zero, and have obliterated smallpox worldwide.  Medical technology has given us remarkable diagnostic tools, such as MRIs, medications, and complex surgical procedures. Our understanding of risk factors and disease prevention has increased; death rates from stroke and coronary heart disease have decreased dramatically in the last 25 years.

All of these advances may improve life and prolong a healthy life. But, please note that I said may.  Since, in many cases, we know that they do.  But, although many lives are longer, they are not necessarily lived in good health.  Thus, the current benefits of medical science pose a fresh challenge to science itself and to scientists — not just to conquer disease, but to learn more about what constitutes good health in older people and to apply that knowledge to the growing population of older men and women in America.

Focus on Health and Disease

Let me emphasize this last point.  The National Institutes of Health conducts and funds research inquiring into the nature of a variety of diseases in hopes of finding ways to prevent, treat, and even cure them.  But, the NIH and its 21 individual research institutes and centers also focus on understanding good health and normal development, including the process of aging, and finding ways of improving health at all stages of life.

Setting Research Priorities

Given the enormous range of diseases and disorders that afflict human beings and given its very generous, but, nevertheless, finite budget, the National Institutes of Health must establish priorities in the funding of research.  This is a complex undertaking.  If, for example, we decided to allocate funds based exclusively on the number of people who have a particular disease, we would have abundant research on colds and allergies, but practically none on childhood cancer.  If funding were based exclusively on the number of deaths caused by a disease, we would neglect chronic diseases, such as arthritis or schizophrenia.  The same is true of other criteria, like economic or social costs, the degree of disability caused by a disease, or the loss of productivity and comfort. Simply put, no one exclusive criterion will work.

In addition to considering the burden of illness as we set priorities for research, it is critical that we see and seize scientific opportunity as it arises. What opportunities hold the most promise for new knowledge? What knowledge will give us a key insight into a disorder or a disease?  And then, what application can we derive from that insight? We know that the most significant and rapid advances are likely to occur when new, often unexpected, findings suddenly expand experimental possibilities.

Furthermore, it is clear some problems seem intractable, regardless of their importance to public health, and must await some technological breakthrough or fundamental new understanding before they can be fruitfully approached.  We try, metaphorically, to graph the scientific opportunity along one axis while keeping it in relationship to criteria such as disease prevalence or a social cost graphed along the other.

Of critical importance to our decision-making is our commitment to support only work of the highest scientific caliber.  Thus, all requests for research funds must pass stringent review for scientific quality.  And, allocating the NIH budget becomes even more complex, because while the NIH places focus on combating specific diseases, we also place a high priority on funding basic laboratory research that underpins our effort.

Such research projects may appear initially to be unrelated to any specific disease, but often prove to be critical turning points in a long chain of discoveries leading to improved health.  In fact, the great breakthroughs are not the sudden discoveries of a lone investigator, but the aggregation of numerous small findings and insights, many of which may have seemed altogether unrelated.  Thus, by supporting basic and disease-related research projects simultaneously, the NIH can achieve both near-term improvements in the prevention, diagnosis, and treatment of specific diseases as well as produce fundamental new knowledge that will set the stage for many advances and medical applications in the future.

Alzheimer's Disease

Certainly, this two-pronged approach to research applies to our efforts in regard to Alzheimer's disease. Alzheimer's disease is a priority for the NIH — particularly for the National Institute on Aging — because pressing public health needs and scientific opportunity have come together.  About four million Americans now suffer from Alzheimer's disease, and an estimated 360,000 new cases will be diagnosed annually.  The prevalence of Alzheimer's disease doubles every five years after age 65, meaning there will be dramatic increases in the number of new cases as the population ages.  Consider that about half the residents of nursing homes have Alzheimer's disease, and then consider that the average annual cost of living in a nursing home is nearly $50,000. Merely delaying the onset of Alzheimer's disease by 5 years — even without treating or preventing the disease — could obviously have a major impact on people's lives and the costs of care.

We know from basic research that Alzheimer's disease follows a complex cascade of events, influenced by genetic and other factors, which take place, over time, inside the brain. These events cause the brain to develop the typical "plaques and tangles" of Alzheimer's disease, to lose nerve cells and to degrade the connections between them in a process that eventually affects normal brain function.  Our advances in understanding this total process have been substantial, and the ability of researchers to conceive of effective treatments has been enhanced by the discovery of enzymes that are implicated in producing the amyloid peptide that forms the plaques.  Understanding how these enzymes work will speed the development of interventions to block their action and stop the development of plaques.

And, just last week, we had an encouraging progress report that underscores the relationship between basic research and clinical application.  Nasal administration of synthetic beta amyloid peptide was found to reduce the development of potentially damaging Alzheimer's disease-like plaques in the brains of test mice. The brains of mice treated with the nasal spray had, for example, a 60 percent lower "plaque burden" in the part of the brain crucial for memory, than did mice that were not immunized or were treated with another protein. Some day, this treatment may be tested in humans for its ability to "vaccinate" against plaque formation in people with Alzheimer's disease.

And, thanks to our investment, over many years, in basic research, we are able to use even more potential interventions in clinical trials. For instance, in 1999 we launched the first large-scale clinical trial to prevent Alzheimer's disease. This trial, being conducted at 65 medical institutions in North America, will evaluate the effectiveness of vitamin E and a drug called donepezil (its trade name is Aricept) in slowing or stopping the conversion from mild cognitive impairment to Alzheimer's disease.

Other prevention trials will examine:

At present, there are only two FDA-approved treatments for Alzheimer's disease — tacrine and donepezil — but there are currently 50 to 60 drugs in various stages of testing that have shown promise either in treating the symptoms associated with Alzheimer's disease or in slowing the progression of the disease. While Alzheimer’s disease remains devastating for patients and families, there is increasing hope that we will find ways to delay, prevent, or treat the disease in the future.

More Emphasis on Clinical Trials

These studies in humans that I have just described emphasize an important point. Although, as I said earlier, fundamental laboratory research is a priority of the NIH, we are conducting and supporting more clinical trials than ever because basic studies have given us so many opportunities and leads that can now be profitably studied in human populations.  You might say that the value of basic research can be reflected in the number of trials that can be undertaken.  Indeed, we have entered a new era of evidence-based medicine, in which we place a high premium on testing medical practices by rigorous scientific standards.  In addition to the imperative to help patients in medical need, the country simply cannot afford to pay for treatments that don't work.

We are all greatly excited by ideas and methods that do work. And, so, we

hope that people, particularly older people, with serious diseases, such as Alzheimer's disease, cancer, heart disease, and arthritis, will enroll in the important clinical trials that NIH is supporting.  A recent Executive Order by the President should act to encourage older people to enroll in such clinical trials.  It directs the Health Care Financing Administration to reimburse providers for the routine medical costs of Medicare beneficiaries who are enrolled in such clinical trials.  This will provide increasing numbers of older patients with access to the newest drugs and treatments.  The NIH, in turn, will gain knowledge about the effectiveness and risks of these interventions for older patients.  This new opportunity for older patients may have an even more profound effect on successful treatment of disease.  There is great hope that if we can involve more adults, especially older adults, in clinical trials, we can make tremendous progress against the diseases with which they are afflicted.

The Women's Health Initiative

We are already making progress in expanding the inclusiveness of medical research. American women — who make up 58 percent of the population over age 65 — still have more questions than answers when it comes to many of their crucial health concerns, especially their health after menopause and into their older years. The answers to many of these questions are finally within sight. They will come from the NIH Women's Health Initiative, a 15-year exploration of how to prevent the major cripplers and killers of older women: coronary heart disease, breast and colon cancers, and fractures from osteoporosis. This study was launched in 1991, in part to redress the concerns that women had not been included in many ground-breaking clinical trials in earlier decades but also to understand the health needs of this population. This study has sparked the interest of older women throughout the country. Today, 162,000 American women, between ages 50 and 79, about 18 percent from minority groups, are participating through 42 centers nationwide. One part of the Initiative — a clinical trial — is testing the effects of hormone replacement therapy, diet modification, and calcium and vitamin D supplements on heart disease, osteoporosis, and colorectal cancer risk.  Another part of the Initiative is an observational study looking for predictors and biological markers of disease.  Women receive no specific intervention, but their medical history and health habits are followed for about 9 years.  When the Initiative is completed and the first results begin to be released, in about five years, we should be able to provide women with much better scientific evidence as to how to prevent the most critical health problems they face in older years.

Declining Rates of Disability

Although the payoffs from the research I've been citing may be several years away, there is considerable good news to talk about now.  Disability rates for people age 65 and older have been dropping at an increasing pace since 1982, and the benefits of this trend extend to both men and women, and include minority groups. Initial reports from the 1999 phase of the National Long-Term Care Survey indicate that disability rates are continuing to fall. However, we need more research to understand the genetic and environmental factors responsible for prolonged good health and extreme longevity, to understand the causes and economic consequences of the decline in disability rates and to accelerate these improvements.

I am aware that this conference is about "technology and the aging," and much of the research I have described is technologically advanced.  But, sometimes answers may be "low tech."  Scientists are increasingly uncovering the benefits of exercise, especially for older people, in preventing or delaying the onset of disease and disability. It has been shown that moderate physical activity can reduce the risk of falls and benefit people with osteoarthritis and depression; and may enhance learning, memory, and even the generation of brain cells. There is also scientific evidence that exercise may be a factor related to increased life expectancy and the number of years that people live free of disability.  A recent study has shown that becoming fit, even in later years, is associated with lower mortality rates.  Anecdotes tell us that more and more older people are now suffering sports injuries, a possible indication that more older people are getting more — and more vigorous — exercise.  These studies and anecdotes show that exercise can benefit older people, and that it is never too late to start.

Conclusion

Let me close with a few comments that may enrich the context of your break-out sessions.  I said earlier that scientific progress is not the work of lone researchers, but an aggregation of research and an aggregation of knowledge.  And, I hope I made clear

the importance of supporting both basic and clinical research, of seeing them as partners, not competitors.  The same ideas of partnership and aggregation are expanding, leading to the formation of new relationships among government, academia, and private industry.  For example, through the NIH Bioengineering Consortium, we now support very large, technically complex projects in academia and industry that take advantage of the best in cutting-edge science and technology to develop, for example, an artificial retina to retain eyesight or to restore it for the blind.  I could multiply this example, but that is not my point.  The point, rather, is this: we must take advantage of the best wherever it may be and wherever we may find it — by collaboration between medicine and science. And the reason is simple. We owe our longer lives to medicine and science; they, medicine and science, will bring us — all of us — ever better, longer, and healthier lives.