MEDICAL DEMOGRAPHY OF DEMENTIAS OF AGING

NIH GUIDE, Volume 21, Number 23, June 26, 1992



PA NUMBER:  PA-92-88



P.T. 34



Keywords:

  Senile Dementia 

  Demography 

  Health Care Economics 

  HEALTH CARE 



National Institute on Aging



PURPOSE



The Rising Prevalence of Dementias:  The dementias associated with

aging are caused by more than 70 disorders and diseases; Alzheimer's

disease (AD) alone is estimated to account for 60 to 70 percent and to

be the major cause of institutionalization among the oldest old. The

precise causes and variable courses are under intensive investigation

(e.g., program announcement (PA), The Epidemiology of Alzheimer's

Disease and Other Dementing Disorders of Older Age, NIH Guide Vol. 15,

No. 18).  But the multidimensional impact of AD and other cognitive

impairments of aging ---on economic and social resources, as a cause of

social dislocations, and on society in general--- is only belatedly

gaining attention, and is a focus of this PA.



The incidence and prevalence of these dementias and cognitive

impairments of aging are determined both by the underlying etiology of

the disease and the processes that define the size and composition of

the at-risk population.  At the same time, AD itself is a significant

determinant of other demographic patterns among the aged, e.g., living

arrangements, household composition, extent of institutionalization,

health care expenditures, and intergenerational transfers (economic and

service). Changing demographic patterns among younger adult cohorts, on

the other hand, will condition the nature and extent of resources

available for caretaking and caregiving.  (See PA, "Alzheimer's Disease

and Related Disorders: Issues in Caregiving" NIH Guide for Grants and

Contracts, Vol. 18, No. 6, February 24, 1989.)



Medical demography is the application of demographic concepts, models,

and techniques to the analysis of the dynamics of morbidity and

mortality at all ages.  The consequences of health, sickness,

accidents, disability, and death for the size, composition, and

structure of the population are projected.  Medical demography is also

integrally concerned with the economic, social, and policy impacts of

these dynamics.



Medical demography proceeds by examining the factors that explain

variations in health and functional transitions across populations,

taking into account the factors that influence health and longevity of

the individual.



The link between the risk factors of individuals and the effects on

population-level outcomes is a central focus of the discipline.

Medical demography estimates the multiplicity of consequences

attributable to diseases---singly and in interaction with one

another---and the elimination or control of each.  Medical demography

describes and measures effects not only by changes in incidence and

prevalence, but also by the contribution of changes in incidence and

prevalence to the disease-alteration patterns of comorbid conditions

and disability, as well as to future shifts in relative risk,

population structure, social structures, and health care systems.  The

complexity of such estimations warrants the increasing reliance of

medical demography on the construction and application of analytically

rigorous models capable of combining several data sets derived from the

same or similar populations.



HEALTHY PEOPLE 2000



The Public Health Service (PHS) is committed to achieving the health

promotion and disease prevention objectives of "Healthy People 2000,"

a PHS-led national activity for setting priority areas.  Potential

applicants may obtain a copy of "Healthy People 2000" (Full Report:

Stock No. 017-001-00474-0) or "Healthy People 2000" (Summary Report:

Stock No. 017-001-00473-1) through the Superintendent of Documents,

Government Printing Office, Washington, DC 20402-9325 (telephone

202-783-3238).



ELIGIBILITY REQUIREMENTS



Applications for research grants may be submitted by public and

private, for-profit and non-profit organizations, such as universities,

colleges, hospitals, and laboratories.  Women and minority

investigators, in particular, are encouraged to apply.  Foreign

institutions may apply, but are advised to consult National Institute

on Aging (NIA) staff before applying and are strongly encouraged to

apply in collaboration with a U.S. institution.  Foreign institutions

are only eligible for the research (R01) and conference grant (R13)

mechanisms.



MECHANISMS OF SUPPORT



The primary mechanisms for support of this initiative are the research

project grant (R01), program project grant (P01), First Independent

Research Support and Transition (FIRST) Award (R29), conference grant

(R13), and Special Emphasis Research Career Award in Demography and

Economics (K01).



RESEARCH OBJECTIVES



Medical demography, which implicitly acknowledges the recursive

relationship between disease structure and population structure,

presents a unique context within which to examine the determinants and

consequences of many chronic diseases of aging.  It is especially

useful for both scientific and public policy research into the complex

impacts of the dementias and cognitive impairments of aging.



This announcement specifically focuses upon the dementias associated

with aging (including AD) and related cognitive impairments without

specific diagnoses.  Investigators may also, however, propose research

in which medical demographic methods are applied to other chronic

diseases associated with aging.



Areas for general research efforts by medical demography include

determination of how the incidence and prevalence of these disorders

are influenced by specific demographic variables of the population,

such as size, age composition, and socioeconomic characteristics.

Building on the contributions of epidemiologic, clinical, and related

research, medical demographers should translate data on

individual-level risk-factor modification into population-level

projections for these disorders.  Such analyses and projections are

necessary for operationalizing new clinical and epidemiologic findings

in estimates of the savings associated with postponing or elimination

of AD and other dementias of aging, the effects of AD and cognitive

impairment on prospective trends in active and disabled life

expectancy, and on needs for long-term care at home and in

institutional settings.



Examples of specific substantive research activities of interest

include, but are not limited to:



o  Estimating the impact of dementias on healthy and institutionalized

life expectancy;



o  Estimating the consequences of controlling mortality associated with

other specific chronic diseases among the elderly for the distribution,

severity, and duration of AD and other dementias in this population;



o  Employing methods of stochastic processes to improve current

population estimates and future projections of AD and other dementias,

especially as they relate to the estimation of demand for long-term

care in institutional and home settings;



o  Clarifying the relationship between AD (and other dementias),

associated comorbid conditions, and the decision to institutionalize;



o  Estimating the impact of demographic processes and changes on the

future distribution of, and responses to, AD and other dementias with

respect to:



-  available familial and household caregiving resources, especially of

spouses and adult children



-  employment/caregiving trade-off patterns of adult children and

consequences for foregone earnings and retirement income



-  duration of in-home care under various mixes of caregiver types and

services



-  determinative effect of disease progression on rate and intensity of

in-home care and on rate of institutionalization;



o  Estimating the nature, patterns, and rates of dissavings among

persons with AD, and:



-  the impact on the household in which they reside



-  the differences from dissavings among the aged without AD



-  the effect of institutionalization on dissavings.



o  Clarifying the precise way in which any of the foregoing estimates

of the medical-demographic distributions and other aspects of dementias

are likely to have a differential impact in minority or rural

populations or among the oldest old.



Investigators are encouraged to consider undertaking secondary analyses

of existing data sets or those being developed, from epidemiologic

surveys of AD supported by the NIA.  When undertaking such secondary

analyses, investigators are encouraged to consider appropriate

consultation with neuroscientists in the interpretation of relevant

clinical aspects of data.



This PA does not replace, but rather supplements, previous PAs of the

NIA, including:  Forecasting Life and Health Expectancy in Older

Populations (NIH Guide for Grants and Contracts, Vol. 20, No. 34,

September 13, 1991); Economics of Aging, Health, and Retirement (NIH

Guide for Grants and Contracts, Vol. 20, No. 15, April 12, 1991)

especially for economic costs of illness; Oldest Old (NIH Guide for

Grants and Contracts, Vol. 13, No. 13, December 7, 1984); Epidemiology

of Alzheimer's Disease and Other Dementing Disorders of Older Age (NIH

Guide for Grants and Contracts, Vol. 15, No. 18, September 19, 1986);

Demography and Economics of Aging (SERCA) (NIH Guide for Grants and

Contracts, Vol. 20, No. 17, April 26, 1991); Alzheimer's Disease and

Related Disorders: Issues in Caregiving (NIH Guide for Grants and

Contracts, Vol. 18, No. 6, February 24, 1989).



Applicants are urged to obtain copies of these other relevant

announcements from the Demography and Population Epidemiology Office

(see INQUIRIES).



STUDY POPULATIONS



SPECIAL INSTRUCTIONS TO APPLICANTS REGARDING IMPLEMENTATION OF NIH

POLICIES CONCERNING INCLUSION OF WOMEN AND MINORITIES IN CLINICAL

RESEARCH STUDY POPULATIONS



NIH and ADAMHA policy is that applicants for NIH/ADAMHA clinical

research grants and cooperative agreements will be required to include

minorities and women in study populations so that research findings can

be of benefit to all persons at risk of the disease, disorder or

condition under study; special emphasis should be placed on the need

for inclusion of minorities and women in studies of diseases, disorders

and conditions which disproportionately affect them.  This policy is

intended to apply to males and females of all ages.  If women or

minorities are excluded or inadequately represented in clinical

research, particularly in proposed population-based studies, a clear

compelling rationale should be provided.



The composition of the proposed study population must be described in

terms of gender and racial/ethnic group, together with a rationale for

its choice.  In addition, gender and racial/ethnic issues must be

addressed in developing a research design and sample size appropriate

for the scientific objectives of the study (see instructions for PHS

398 (rev. 9/91), page 22).



Applicants are urged to assess carefully the feasibility of including

the broadest possible representation of minority groups.  However, the

NIH recognizes that it may not be feasible or appropriate in all

research projects to include representation of the full array of United

States racial/ethnic minority populations (i.e., Native Americans

(including American Indians or Alaskan Natives), Asian/Pacific

Islanders, Blacks, Hispanics).  The rationale or studies on single

minority population groups should be provided.



This policy applies to all studies submitted under this program

announcement.  The usual NIH policies concerning research on human

subjects also apply.  For foreign awards, the policy on inclusion of

women applies fully; since the definition of minority differs in other

countries, the applicant must discuss the relevance of research

involving foreign population groups to the United States' populations,

including minorities.



If the required information is not contained within the applicant, the

review will be deferred until the information is provided.  Peer

reviewers will address specifically whether the research plan in the

application conforms to these policies.  If the representation of women

or minorities in a study design is inadequate to answer the scientific

question(s) addressed AND the justification for the selected study

population is inadequate, it will be considered a scientific weakness

or deficiency in the study design and will be reflected in assigning

the priority score to the application.  All applications are required

to address these policies.  NIH funding components will not award

grants that do not comply with these policies.



APPLICATION PROCEDURES



Applicants are to use the research project application form PHS 398

(rev. 9/91) that is available at the applicant's institutional research

office and from the Office of Grants Inquiries, Division of Research

Grants, National Institutes of Health, 5333 Westbard Avenue, Westwood

Building, Room 449, telephone (301) 496-7441.  The title and

announcement number, Medical Demography of Dementias of Aging,

PA-92-88, must be typed in Section 2a on the face page of the

application.



The application and five copies must be mailed or delivered to:



Division of Research Grants

National Institutes of Health

Westwood Building, Room 240

Bethesda, MD  20892**



Receipt dates are February 1, June 1, and October 1 of each year.



REVIEW PROCEDURES



R01 and R29 applications will be reviewed for scientific and technical

merit by an appropriate Initial Review Group of the Division of

Research Grants.  All other applications (K01, P01, and R13) will be

reviewed by an appropriate ICD review group.  Secondary review will be

by an appropriate National Advisory Council.  Applications will compete

on the basis of scientific merit and the traditional review criteria

specific to each mechanism will apply.



AWARD CRITERIA



Applications will compete for available funds with all other approved

applications assigned to that institute, center, or division.  The

following will be considered in making funding decisions:



o  Quality of the proposed project as determined by peer review

o  Availability of funds

o  Program balance among research areas of the announcement



INQUIRIES



Potential applicants are encouraged to discuss their project with NIA

staff in advance of formal submission.  This may be accomplished by

calling or writing the program office listed below.



Direct inquiries regarding programmatic issues to:



Dr. Richard Suzman

Demography and Population Epidemiology

National Institute on Aging

Gateway Building, Room 2C-234

Bethesda, MD  20892

Telephone:  (301) 496-3136



For fiscal and administrative matters, contact:



Ms. Linda Whipp

Grants and Contracts Management Office

National Institute on Aging

Gateway Building, Room 2N-212

Bethesda, MD  20892

Telephone:   (301) 496-1472



AUTHORITY AND REGULATIONS



This program is described in the Catalog of Federal Domestic Assistance

No. 93.866.  Agency Research Awards will be made under the authority of

the Public Health Service Act, Title III, Section 301 (Public Law

78-410, as amended; 42 USC 241 and 41 USC 289) and be subject to PHS

Grant Policies and Federal Regulations 42 CFR Part 52 and 45 CFR Part

74.  This program is not subject to the intergovernmental review

requirements of Executive Order 12372 or Health Systems Agency review.



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