This year's theme is in my judgment of central importance in all of our efforts to meet the needs for care in older persons: the full dignity and autonomy of each individual older person must be recognized and respected; our approaches to care and delivery of services must be con-ducted with the chief goals in mind of maintaining, restoring, and respecting the independence and individuality of each older person.
The perspectives which I bring to this theme come principally from my experiences of the last eight years as Director of the National Institute on Aging, as well as acquaintance with innovative programs of care in the United States and other countries. The National Institute on Aging, now in its 17th year, has its overall mission the conduct of research and research training on the biomedical, behavioral and social aspects of aging processes and the common problems of older persons. This is indeed a very broad mission; actually I believe we can see how it relates to three major areas of achieving care with dignity for older persons: 1) maintenance of health and independence; 2) restoration of function and autonomy among those who are frail; and 3) truly individualized care, as preferred by those needing it, whatever their degree of mental or physical frailty.

1. MAINTAINING HEALTH AND INDEPENDENCE
One of the most striking changes in our perspectives about old age, as a result of recent advances in research, is our understanding of the potentials for maintaining health and independence. We now know that we must replace our earlier, pervasive views, that old age is a time of inevitable declines in physical function, mental function, sexual and social functions, - replace these views with the recognition that most of our human functions can be and often are maintained into very late years. Let me give some examples from recent research.
Studies at the Gerontological Research Center of the National Institute on Aging, in Baltimore, Maryland, as well as studies elsewhere, have documented the potential for maintaining a very good cardiac output -heart function - into the 80s and possibly longer, in persons who are demonstrably free of coronary heart disease. Figure 1 illustrates how subjects, healthy subjects, were screened first, with measurement of both resting and stress-tested evidence for occult heart disease using the electrocardiogram and thallium scan. Approximately 50% of these subjects in fact had evidence of coronary heart disease. Among the other 50% who had no heart disease, Figure 2 shows that the maximum cardiac output achieved on the standard tread-mill stress test was as good in subjects in their 70s and 80s as in much younger subjects. There was considerable variability at all ages, but a number of the oldest subjects did just as well as the youngest, and there is no evidence for any downward trend with age.

Fig. 1 Prevalence of Coronary Artery Disease

Fig. 2 Relationship between Age and Cardiac Output

Furthermore, in followup studies of 5 years or more, in persons who have no evidence on these tests for coronary heart disease, the risk of having a heart attack is very small - ap-proximately 3% in the next 5 years; and this risk is as small in those in the age range 60 to 69 as in those aged 40 to 59. In contrast, in those of any age who have evidence of even occult heart disease the risk of having a heart attack is much higher. I have used this type of evidence to support the position that, rather than having any arbitrary age for compulsory retirement, such as the age-60 limit on commercial airline pilots in the United States, we would be much wiser to use such tests to determine risks or lack of risks in each individual.
Another example of maintenance of healthy functioning into late years is that of the brain and mental performance. In studies of the brain's metabolism, at the National Institute on Aging, using the positron emission tomography technique for measuring alucose metabolism, it has been shown that healthy persons in their 80s have essentially the same levels of brain metabolism as much younger persons. Figure 3 shows typical examples. The following Figure 4 illustrates by contrast what is seen on PET scan in a person with dementia of the Alzheimer type: here are presented two identical twins, in their 60s, one of whom as developed Alzheimer's disease. His scan shows marked decreases in glucose metabolism in many areas of the brain, in contrast to the normal twin.

Fig.3

Fig.4

Furthermore, in extensive studies of a longitudinal nature of mental functioning, Professor Warner Schaie of Pennsylvania State University has documented, as the next Table 1 illustrates, that a large proportion of older per-sons may perform just as well on a number of different tests of mental function as the average 25-year-olds; and, as shown in the next Figure 5, that the individual's performance by most subjects does not decline over 7-year follow-up, even in those in their 60s and 70s. In all of the examples I have been giving we simply have little or no information yet on subjects in their 90s and beyond.

Table 1 Percentage Overlap of Score Distributions at various Ages with the Distribution of the Youngest Subgroup (Age 25)

Fig. 5

Again in contrast to earlier, cross-sectional studies of the function of the kidneys in relation to age, which appeared to show general decline in function, the results of the longitudinal studies of the Baltimore Longitudinal Study on Aging show (Figure 6) that in many persons - at least a third or more - there is no decline for that individual.
These studies illustrate the importance of longitudinal measurements in the same per-son, and again the extensive variability even among presumably healthy persons. In my judgment the greatest challenge now in aging research, in almost all aspects, if to try to understand the reasons for the variabilities between individuals.

Fig. 6

Still another example of the stability across the life span comes from longitudinal studies of personality characteristics in the Baltimore longitudinal subjects: personality characteristics are remarkably stable and unchanging; whatever we are like when we are younger we will likely be the same in later years.
Not only is there the potential for maintaining good function in most ways, there is also the potential to improve function if one has tended to have some declines. Physical fitness and exercise programs are justifiably popular and to be encouraged at all ages, with adjustments if necessary for any underlying disease or disability conditions. Figure 7 illustrates how persons in their 60s and 70s who choose to train to be masters' athletes can have maximum aerobic capacities far higher than typical non-exercising older persons, and indeed virtually as high as young athletes. In studies of the results of enrolling in a fitness program by previously sedentary persons in their 60s and 70s, Professor John Holloszy and his colleagues at Washington University, Saint Louis, have shown that these older persons increased their maximum aerobic capacities as much on average - almost 40% - as did younger subjects, and also had marked improvement in their blood lipids and in glucose tolerance. In post-menopausal women they demonstrated less bone loss with exercise than otherwise occurred and even an increase in bone density in some persons with exercise. It is never too late: in an impressive study published in 1990 by Dr. Maria Fiatarone and colleagues from Boston, they showed that in a group of very frail persons in a nursing home, with an average age of 90, 8 weeks of simple muscle-building exercises produced marked improvement in leg muscle strength, muscle mass, and ability to walk around.

Fig. 7

Similar evidence exists about the potential for improving mental functioning. Professor Paul Baltes and colleagues in Germany, and other groups, have demonstrated improved mental performance after simple training exercises in older persons with some deficiency in mental function.
Thus in summary it seems clear that many, indeed most, persons have the potential to maintain good levels of function and independence into very late years, and even to regain it if they have tended to let it decline. The key ingredients are sound, active life styles including maintained physical and mental exercise, appropriate nutrition, avoidance of smoking, minimal if any alcohol, and appropriate screening/preventing measures.

2. RESTORING FUNCTION AND AU-TONOMY AMONG THOSE WHO ARE DISABLED
At the same time, we know that as more and more people live into later and later years, in-creasing numbers will develop chronic conditions, due to genetic predispositions, life style factors, and environmental exposures. Table 2 shows, from national surveys in the United States, the frequency of reporting of the most common chronic conditions in those aged 65 and older. Almost one-half report some degree of arthritis; other very common conditions are hypertension, loss of hearing and vision, heart trouble. Not all of those who report some symptoms in these areas have loss of function, but in particular in those aged 85 and older the loss of function is quite common, as shown in Table 2. Among those aged 85 and older almost 40% have loss of function to the extent that they need help from another person every day. The most common causes of this degree of loss of function in those aged 85 and older are shown in Figure 8: loss of mental function or dementia is the most common, followed by arthritis, peripheral vascular disease, strokes, and fractures of the hip or other bones. It is important to note that the major causes of mortality, the major killers, i.e. heart disease and cancer, cause relatively little sustained morbidity or loss of function. Thus in developing research and services aimed at addressing the major causes of the burdens of disability in older persons the predominant attention has been given to dementia or mental frailty, and the causes of physical frailty including arthritis, osteoporosis, risk factors for falls, and losses of hearing and vision, as well as strokes. Achieving goals of restoring function and autonomy requires addressing these challenges.

Table 2 Percent of Older People Who Need the Help of Another Person

Fig 8 Probability of Selected Medical Conditions among Disabled Persons, 85 Years and Older (rank order)

Dementia is clearly the greatest threat to in-dependence in older persons, in most if not all of the world's populations. In the United States the latest studies indicate that more than 10% of persons over the age of 65, and over 40% of those over age 85, have a significant dementing condition, predominantly of the Alzheimer type. Currently available data indicate lower levels of prevalence of Alzheimer's dementia in Europe and Japan (Figure 9), with perhaps higher frequency of multi infarct dementia in Japan. The difference may be due in part to the methods used to document dementia, and we have very little reliable information from other parts of the world. A major study is just being undertaken by the World Health Organization Program on Research in Aging, to obtain more extensive and more comparable epidemiological data on the prevalence, and ultimately the incidence, of dementia of all types in a number of countries, both developed and developing.

Fig 9 Estimated Prevalence of Dementia among Persons Aged 65+

The burdens of care of demented older persons, on their families and on society, are enormous, and the costs are staggering: the current estimate is a cost of over $80 billion per year for care of persons with Alzheimer's dementia in the United States, and this cost will rise rapidly with the rapid increase in numbers of very old persons unless we can halt this disease. Thus support for research on all aspects of Alzheimer's disease is the highest priority of the National Institute on Aging, as well as being a high priority for other agencies and foundations. We simply must, and I believe we can, find definitive answers to Alzheimer's disease, within the remaining years of this century.
Fortunately, research already accomplished and under way is giving very promising leads to potential causes, to the processes of development of the damaging changes in the brain, and to potential points where we may be able to intervene to halt or reverse this disease. There is clearly a genetic predisposition in at least some families and the actual sites and actions of these abnormal genes are rapidly being identified. But factors other than genetic must also enter in, as indicated by studies of identical twins; in many instances one twin only has developed Alzheimer's disease even though the twins have identical genes. Thus we must continue to look for external factors, in the diet or food chain, in other environmental exposures, possibly involving infectious agents. There are also very promising leads to interventions which may halt the progress or even re-verse the damaging changes: the identification and experimental use of nerve growth factors, in experimental animals, has been shown to correct, at least partially, damage in the brain and we may expect to see careful clinical trials of such growth factors in persons with Alzheimer's disease and other degenerative diseases like Parkinson's disease in the near future. A number of drugs are also being tested for possible value in halting the progress or relieving the symptoms.
While such research and development is proceeding, we face the major challenges of providing care with dignity to those already afflicted with Alzheimer's disease, and support for their stressed families. Our goal again is to preserve and restore as much normal functioning, as much individual choice and independence, as possible. Careful attention to the life background and preferences of each individual is essential, with continued searching for what features of daily life may be most in keeping with that person's longstanding preferences, most supportive of their continued autonomy. I will return to some of these features and to alternative living settings.
Physical frailties also present major challenges, for basic research and for restorative, rehabilitative treatments. One of the most disabling results of falls and underlying osteoporosis is fracture of the hip, of which over 200,000 occur per year in the United States. The risk of hip fracture rises exponentially with age, to such an extent that one of every three women who reach the age of 90 will very probably fracture her hip. Fortunately again much progress is being made in understanding the factors which contribute to development of osteoporosis and to initiating steps which can prevent or halt this condition. I have already referred to the importance of active exercise in maintaining bone density. The latest evidence indicates increased justification for use of estrogens in post-menopausal women, at least in women are at especial risk for osteoporosis and who do not have special risk factors for breast cancer. Other preventive measures, including adequate intake of calcium and vitamin D. are important.
And new methods of treating ostoeporosis with agents that halt the loss of bone, and potentially with agents like growth factors which may help restore bone, are promising. We should be able to delay and diminish greatly the occurence of hip fractures within the next few years. As the Figure 10 shows, if we could delay its occurrence by even as little as 5 years we would reduce by one-half the numbers of persons afflicted and thus reduce by half the multi-billion dollar yearly costs.
Related advances are also being made in understanding the risk factors for falls in older persons, which result in many other injuries in addition to hip fractures and which, through the fear they produce, contribute to loss of independence.

Fig. 10 Deaths per 100,000 Population U.S. 1977



In these conditions and other major causes of physical limitations, e.g. Strokes, arthritis, it is essential that a rehabilitative philosophy and approach be an integral part of treatment. The goal of geriatric medicine should be rehabilitative, the restoration of lost functions and re-establishment of as much independence as possible. This rehabilitative approach should begin as early as possible after any acute event and should be continued far longer than is usually done. We have learned that weakened muscles, loss of sense of balance, impaired gait, can be improved in major degrees with sustained efforts in even the oldest and most disabled persons.

3. INDIVIDUALIZED CARE
The concept of individualized care is not new, and in simple terms is a restatement of the basic philosophy of all medicine: Dr. Francis Peabody stated it memorably in his lecture on "The Care of the Patient." :"The secret of the care of the patient is in caring for the patient". That is, paying attention to what matters to that individual. But with the pressures of the commonly multiple complicating conditions, both medical and social, facing many older patients, the complexities of care needed, and the growth of many different settings for providing long term, continuing care in addition to the person's own home, there have been strong tendencies to lose sight of the individual - to try to make the system work, to fit the person into the system rather than fit the system to the person.
Part of the problem has been the often incomplete evaluation of the multiple problems being faced by a frail older person and family, at some critical juncture such as a progression of disability or a breakdown in the family support capabilities. It is in these situations that the value of comprehensive, multidisciplinary geriatric assessments have been apparent. These thorough evaluations, by geriatrically knowledgeable physician, nurse, social worker, and often others like dietitian, pharmacist, psychiatrist or psychologist, dentist, physical therapist, occupational therapist, other consultants, as needed, with team development of a comprehensive plan of care including again a major emphasis on restoration of function and independence, have contributed considerably to better outcomes for the affected older persons and their families. Almost invariably features of that individual are identified which are important and which would have been missed otherwise.
Another major problematic area has been the institutional environments in which a significant and growing proportion of long term care for very frail older persons occurs. In the United States the likelihood of spending some portion of one's later years in a nursing home reaches 60% for women who live into their 80s. As already referred to, there is growing concern that the individuality of the person moving into a nursing home is often lost sight of; the person is fitted into the environment and routines of the institution rather than fitting the services of the institution to the individual. This reversal of what is to be desired reaches its worst degree when frail older residents of nursing homes are subjected to physical or medical restraints - when their limited remaining independence is removed by fastening them into a chair or bed or by suppressing their function with psychotropic drugs. Unfortunately in the United States 30 to 40% of residents of nursing homes are restrained some part of every day.
That such unsatisfactory care in institutions is not unavoidable is shown by a number of examples of much more individualized, restraint-free care in nursing homes in several other countries, such as Scotland, Sweden, and Denmark, and in some nursing homes in the United States. In response to these and other concerns about the quality of care in nursing homes, in the mid-1980s at the request of the U.S. Congress the Institute of Medicine of the National Academy of Sciences conducted a careful study an issued a report in 1986 on the problems of quality of care in nursing homes, together with recommendations which were largely incorporated into federal legislation as a part of the Omnibus Budget Reconciliation Act of 1987. This act requires nursing homes, first, to assess the person admitted to the nursing home much more thoroughly, with attention to that person's daily living practices and preferences as well as medical, mental, and social characteristics and needs. The guidelines for this thorough assessment have led to the establishment of a "Minimum Data Set" for each person (which can be computerized) which is then used for comprehensive planning for care by the interdisciplinary team of professionals. The 1987 act also places severe constraints on the use of psychotropic drugs and on the use of･ physical restraints, and stresses improved training of caregivers at all levels.
Simultaneously with the initiation of these new requirements have been the vigorous efforts of professional and lay advocacy groups for nursing home reform and elimination of restraint use. Already much progress can be seen.
With increasing recognition of the wide range and variation in the capabilities, preferences, and needs for supportive long-term care of older persons, there are a number of innovations under way in living environments. These include new designs for homes and furnishings in terms of their potential for "aging in place", i.e. accommodating the changing needs of a person in her/his own home; the development of continuing care retirement communities where more services can be provided when needed; assisted living group homes and apartments; and special care units in nursing homes for severely demented residents. Support for research on various models of such special care units has been provided, and we may expect to learn more about what features of design, staffing, and care plans seem to serve best to help demented older persons to live as autonomously as possible.

4. HEALTH EXPENDITURES
With the increases in chronic conditions which occur with aging it is no surprise that the costs of care rise concommittantly. In the United States, an analysis in 1987 indicates that health expenditures per person aged 65 to 69 were on average $3728, whereas for those aged 85 and older they were $9178 - almost three-fold greater. With the rapidly in-creasing numbers of persons in the oldest ages we can expect to see continuing increases in these costs, unless and until we make further progress in preventing and treating the major disabling conditions. I have already indicated what could be saved through simply postponing the occurrence of hip fractures by five years. Figure 11 shows what could be accomplished in reducing the costs associated with Alzheimer's disease through a 5-year postponement of its onset or progression. The total expenditures for health care, as a proportion of the gross national product, is higher in the United States than in any other country, and is a matter of concern, with many different proposals for attempting to control these costs without sacrificing quality of care. Other countries may be more successful in controlling costs but all will face the same challenges of increasing numbers of old and very old persons. Our common challenge is to give even better care in ways which I believe can in the short and long run actually decrease the burdens and costs.
If we keep our as our primary goal care with dignity for all persons, including specifically our elders; if we give adequate emphasis to research, education, attitudes, and respect, I believe we can make rapid progress towards what we would all like to achieve.

Fig. 11 Effect of a 5-Year Delay in the Onset of Alzheimer's Disease.