Health disparities are associated with a broad, complex, and interrelated array of factors. Risk factors, diagnosis, progression, response to treatment, caregiving, and overall quality of life may each be affected by aspects such as race, ethnicity, gender, socioeconomic status, age, education, occupation, and as yet unknown lifetime and lifestyle differences. The underlying causes of such relationships require in-depth research. Understanding differences and interactions is critical for developing behavioral and public health interventions to reduce burdens of illness and increase quality of life for older persons and older populations.
A1. Advance understanding of the development and progression of diseases and disability that contribute to health disparities in older racial and ethnic minority groups
Action Plan: Family caregivers of persons with Alzheimer's disease are at risk for negative psychosocial and health consequences of chronic stress. The extent of this risk will vary from one individual to another and also may vary from one group to another, depending on the special strengths and problems experienced by members of a particular group. The long term effects of caregiving, nursing home placement and patient death are being compared in white caregivers and in African American caregivers, each compared to appropriate non-caregiving controls. The results will show the longitudinal effects of the stress of continued caregiving, the long-term effects of caregiver adjustment to nursing home placement or death of the patient, and will identify variables that predict individual differences in caregiver adjustment, with special emphasis on strengths and problems of African American families and the long term course of caregiving stress that they experience.
Action Plan: In order to understand the course of normal aging among racial and ethnic populations, it is necessary to develop neuropsychological performance norms for different groups and factors affecting these norms. Two studies in progress should help establish age- and culture-appropriate test norms for neuropsychological assessment of African-American elders. One will investigate the potential influence of several factors on the variance in performance including: age; gender; years of education; educational experience; quality of education; degree of literacy; degree of acculturation. The other study, in addition to the primary goal of developing norms for diverse neurocognitive abilities, will examine the relationship between performance and illness in a senior African American cohort. Additionally, as research on AD focuses on mild cognitive impairment and earlier stages of the disease process, the distinction between AD-related research and that on normal aging is becoming more and more blurred. Examples are the cognitive tests being developed for different ethnic groups within the AD Centers and their satellites, including measures to be used in clinical trials of normal individuals. These instruments will help assess normal cognitive aging as well as development of mild cognitive impairment and AD in minority populations.
Action Plan: At the present time there are limited data on the underlying factors leading to impairments, functional limitations and disability in different minorities. For instance, Mexican Americans represent the most rapidly growing segment of the US elderly population and strategies for prolonging active life expectancy of Mexican Americans have not been fully explored. NIA is supporting an epidemiological study of community-dwelling elderly Mexican Americans and European Americans of low, middle and high SES status from the San Antonio Longitudinal Study of Aging (SALSA). Objectives of the study are to identify potential ethnic differences in the underlying factors leading to impairments, functional limitations and disability due to diabetes and osteoarthritis.
Action Plan: The National Institute on Aging (NIA) Intramural Research Program (IRP), with financial support from the National Institutes of Health (NIH) Office of Research on Minority Health and the NIH Office of the Director, has designed and procured a mobile Medical Research Vehicle (MRV). We will use this vehicle to conduct age-related community based longitudinal and cross-sectional clinical research studies. One of the most vexing problems in clinical research is the unique challenge of recruiting and retaining minority, medically underserved, and socioeconomically diverse populations. The NIA IRP Medical Research Vehicle (MRV) was conceived, designed, and developed as a tool for creating an effective methodology for the recruitment and retention of non-traditional research participants into age-related clinical research. The vehicle is a 53-foot customized semi-trailer with three working areas: an examination room with blood donor station; a cardiovascular fitness and muscle strength testing area; and a bone density/body composition and vascular studies testing area.
Action Plan: The natural history of sleep apnea is being studied in older African-Americans and Caucasians. The focus is on differences between daily fluctuations in blood pressure, sleep disordered breathing (SDB), and possible effects on cognition. African Americans with high blood pressure that does not lower at night may be more prone to oxygen deprivation, possibly related to cognitive impairment for some groups of elderly. Another ongoing study is on the Hmong people. This ethnic group is at high risk for Sudden Unexpected Nocturnal Death Syndrome. Analysis of the interview data on sleep problems in Hmong men and women has indicated potentially important differences between Hmong and Caucasians in the correlates of self-reported breathing disturbances during sleep. Studies of heart rate abnormalities in conjunction with apnea and hypopnea are underway.
Action Plan: NIA has strongly emphasized attention to minority-related issues in its Program Announcements (PAs) on cancer and aging, especially in two PAs: Aging, Race, and Ethnicity in Prostate Cancer, and Aging Women and Breast Cancer.
Action Plan: The NIA joined the National Heart, Lung and Blood Institute in supporting the Honolulu Heart Program (HHP), an ongoing, prospective study of coronary heart disease and stroke among men of Japanese ancestry born between the years 1900 and 1919 and living on the island of Oahu, Hawaii, in 1965. The Honolulu-Asia Aging Study (HAAS), a study of dementia and aging, was added to the HHP in 1991. Approximately 80 percent of the surviving cohort (3,734), then aged 71 to 93 years, was examined and interviewed. The HAAS and the contract with Kuakini Medical Center has been extended through the year 2000 to ascertain episodes of sleep apnea using NHLBI methods and procedures. Autopsy acquisition protocol for neuropathology will continue, pending approval of a research grant to continue specimen collection, analysis and reporting. A study of age, gene/environment susceptibility in etiology based on a family study of diabetes is being implemented.
Action Plan: Cognitive function reflects contexts and environments within which people engage, so research will examine important sources of variation in cognition in the meanings, artifacts, practices, and institutions that structure context and environment in minority populations. Conduct research to determine the conditions under which cognitive instrumental activities of daily living, especially complex cognitive activities are maintained despite declines in underlying basic cognitive abilities.
Action Plan: Enhance ongoing collaboration with NICHD on the New Immigrant Survey that will provide important longitudinal data on the health of ethnic and racial minorities who are immigrants to the US, and their children. Enhance ongoing studies in Mexico and Puerto Rico to understand the origins of health disparities in US Hispanic populations. Consider developing comparable studies in the Caribbean.
Action Plan: Through the NIA Demography Centers and interagency agreement contracts to other US agencies and multilateral organizations, produce projections of burdens and costs of illness, healthy life expectancy, longevity, and mortality trajectories by race and ethnic status. This model would project changes in health differentials that would occur through expected changes in education and economic distributions in the population, net of any public health interventions. Develop more complex behavioral models to specify a health production function for different race and ethnic groups -- in effect develop an input-output model that would show which interventions are likely to have the highest cost/benefit ratios. The model would incorporate known effects based upon completed intervention studies and could also be used to decide which intervention or epidemiologic studies are most needed. The model could also serve a heuristic function in providing suggestions for data needs and in determining the adequacy of sample sizes in terms of needed precision.
Action Plan: Encourage research using NIA supported longitudinal studies with significant minority over-samples, such as the Health and Retirement Study and the Panel Study of Income Dynamics, to monitor the evolving financial status of the older population and to understand how to buffer the economic effect on families of health events and onset of chronic disease.
Action Plan: The Women's Health and Aging Study (WHAS) is a prospective cohort study of community-resident, cognitively intact, women age 65 years and older with moderate to severe physical disability. The overall goal of the study is to understand the causes and course of physical disability, particularly related to the presence and severity of disease. Prior to the WHAS, such a comprehensive, research-focused medical evaluation of functionally limited older adults had not been attempted in a home setting. The comprehensive information on the presence and severity of disease, obtained using physiologic and clinical measures, and the rich data characterizing the dimensions of functioning as well as psychosocial and socio-cultural factors including race (28 percent black), will contribute to increased understanding of the complexities of functional decline in older women. The prospective component of the study will characterize change in function and relate it to underlying changes in disease status, taking into account the impact of medical care, psychosocial factors, and important life events. In addition, the racial and SES composition of the WHAS population enables examination of the joint and independent effects of socio-cultural and economic factors on the severity and progression of disability.
Action Plan: The Salisbury Eye Evaluation (SEE) study, which began in 1992, had an original enrollment of more than 2,500, of which approximately one-fourth are African American. Rates of visual impairment in the areas of acuity, contrast sensitivity, stereoacuity and visual fields were found to be greater in African American than Caucasian participants. These studies will move into tests of dynamic measures of visual function and motion sensitivity. In addition, an extensive battery of cognitive tests will measure learning, memory, verbal fluency and attention in order to better understand the relationship between visual and cognitive changes during aging. In another study, body composition and the chemical senses (smell and taste) will be studied in two groups (20-35 and 65-80 years old) of healthy African American women. It is hypothesized that body composition is related to olfactory dysfunction, which increases as a function of aging. Body composition will be assessed by anthropometric measurements. Usual dietary intakes will be determined through the food frequency questionnaire. Olfactory perception, taster status, dental/oral health, and salivation will be measured by screening tests and interviews. The study specifically over-sampled the African American population of Salisbury, MD, in order to have sufficient statistical power to make direct comparisons between African American and Caucasian subjects.
Action Plan: The Health ABC Study is a longitudinal cohort study with a population of 3,075 people aged 70-79; 46 percent of the women in the study and 33 percent of the men are black. The major objective of this 7-year study is to examine whether loss in muscle, with concomitant increases in fat and decreases in bone, represents a common pathway by which multiple diseases contribute to disability. The study involves characterization of the cohort in terms of the major weight-related health conditions, which contribute to disability: cardiovascular disease, pulmonary disease, osteoporosis, osteoarthritis, diabetes, and depression. By linking these data to detailed functional health measures, the HEALTH ABC Study should contribute to understanding similarities and differences in the progression of disability among older blacks and whites.
Action Plan: Support research using NIA supported longitudinal studies, such as the National Long-Term Care Survey, Longitudinal Study of Aging, and the Health and Retirement Study, to track changing disability rates by race and ethnicity and to better understand ways to maintain and accelerate declining disability.
Action Plan: Support research on the consequences of elder abuse and neglect on all-cause mortality, on the development of clinical practice guidelines to aid health practitioners in recognizing abuse in the elderly population, and on neglect in nursing homes as a consequence of poor nutrition. Commit to a focus on diverse populations and to the conduct of the first nation-wide probability survey of the prevalence of elder abuse and neglect and its associated risk factors.
Action Plan: The NIA asked the National Academy of Sciences to identify areas of research opportunity which would improve our understanding of cognitive functioning and aging, specifically at the intersection of behavioral science, cognitive science and neuroscience. The NAS report has recommended that NIA undertake a research initiative to understand the effects of behavioral, social, cultural, and technological context on the cognitive functioning and life performance of aging persons. This initiative will have a specific focus on older ethnic and racial minority populations.
Action Plan: The Whitehall Study in the United Kingdom found that occupational grade level, even holding many risk factors constant, is associated with a significant fraction of the variation in health by socioeconomic status. A question is whether supervisory status compensates for the negative effects of race. A workshop would help inform the decision about the advisability of a "Whitehall in Washington" study that would be developed by NIA extramural and intramural units along with NCHS, possibly NIOSH, and other ICs.
Action Plan: Following a joint NIA/Fetzer Institute Working Conference, NIA will create a series of research initiatives soliciting research on integrative topics that deal with how and where older Americans die. The initiatives will be sensitive to and specifically solicit research on race/ethnic disparities in the social process of death, the location of death, the involvement of the family in end-of-life, and decision-making process for older diverse populations. Additionally, attention will be paid to how various organizational forms relate to and care for a diverse population at the end of life.
Action Plan: The purposes of this initiative are to explore differing cardiovascular responses to psychosocial challenge; describe differing autonomic responses to psychosocial challenge; and define the interaction of cardiovascular polymorphisms, ethnicity, and cardiovascular and autonomous responses to psychosocial challenge.
Invasive and non-invasive techniques will be used to assess autonomic control of the cardiovascular system during resting conditions and psychosocial challenge. Independent variables will include ethnicity, gender, and genotype. Dependent measures will include heart rate variability, blood pressure variability, impedance cardiography, vascular resistance, nitric oxide and catecholamine levels.
Action Plan: At present there are virtually no data on clinical and pathological ethnic heterogeneity due to the limited numbers of minority patients seen at any one Center. Using larger data sets developed by the NACC and autopsies at individual Centers will allow characterization of the rarer and mixed phenotypes, and genetic and ethnic differences that would not be possible with the smaller numbers of subjects in individual centers. It will allow research on normal aging using control subjects and also the transition from normal aging to mild cognitive impairment to AD. By pooling ethnic and minority patient information and autopsies from many centers, it will also be possible to begin to identify potential biomarkers which will help to diagnose AD, permit characterization of disease course, monitor response to treatment in diverse groups and perform clinicopathological correlations.
This study will characterize traits (intrinsic aging changes versus cardiovascular disease risk factor burden) in a biracial (black-white) population that may influence progression of sub-clinical cardiovascular disease in an aging population. It will expand support of a well-characterized biracial (black-white) population that has been followed for cardiovascular disease risk factors and lifestyles in the Bogalusa Heart Study over the past 25 years into middle age and beyond. New research will provide insight into the interaction between normal aging, including the growth and maturation process in childhood, and predisposing risk factors that may influence development of sub-clinical cardiovascular disease in a black-white population reaching middle age. This initiative will provide a greater understanding of the evolution of cardiovascular disease risk in normal aging and may also lead to improved lifestyle programs for successful aging and longevity, including cardiovascular disease prevention.
Action Plan: There is an unresolved tension between the proximal and distal causes of poor health. Many studies have identified significant risk factors for the development of chronic diseases that pre-date onset of symptoms by at least a decade. Population-based studies in which individuals are tracked from birth to their adult death help researchers observe the continuities and discontinuities in health over time, and have the potential to provide the necessary data to foster understanding of the large variations in health across racial and ethnic populations. Such combined studies would provide us with full life-course data on health and risk factors. This initiative would continue collaborative efforts with NICHD and other countries to understand the impact of early-life factors, including prenatal nutrition in the first trimester, on adult health.
Action Plan: The NIA will contract with the NAS Committee on Population (CPOP) to hold a two-day workshop on racial and ethnic differences in health in late life as a follow-on activity to a workshop organized by the Committee on the same topic in December 1994, which resulted in the volume Racial and Ethnic Differences in the Health of Older Americans (NAP, 1997). The workshop will consider the extent of racial and ethnic disparities in life-expectancy, health, and disability and the extent to which these disparities can be attributed to differences in lifestyle risk factors, access to health care, and other social and economic factors. The workshop will also consider the impact of new OMB definitions of race and ethnicity on health disparities and will chart the scientific progress in this area since the NIA-sponsored 1994 workshop. As a related activity, NIA will encourage research on the impact of changing self-definitions of race and ethnicity, and of the new OMB definitions, on health disparities.
Action Plan: Coordinate demographic and epidemiological studies to identify ethnic, racial, geographical, SES, educational and health factors affecting maintenance of cognitive, sensory and motor health and development of mild cognitive impairment, AD and other age-related neurodegenerative diseases. This program initiative will be undertaken in conjunction with other NIH Institutes as part of the Healthy Brain Initiative, an NIH Area of Emphasis. The initiative should start with analysis of ongoing studies, what they are projected to accomplish and where the gaps in knowledge are in this field. One essential early part of the initiative would be a conference and follow up research to determine and develop standardized measures of cognitive change. The kinds of additional studies to be supported would depend on the outcome of the analysis and conferences. Note: The breadth of this initiative crosscuts each of the research subgoals to include activities associated with: (1) new or improved approaches for detecting and diagnosing, (2) preventing and delaying, and (3) treating disease and disability.
Action Plan: Reports by elderly persons in social science surveys of declining health but high levels of life satisfaction, point to the need to improve our understanding of how well-being, health, and preferences are measured or mis-measured in surveys. The measurement of well-being and satisfaction, individual decision-making to improve well-being, and adaptation are also interrelated with the psychological foundations of economic evaluation. The NIA will consider an initiative on the measurement of well-being which would emphasize interdisciplinary work between economists, psychologists and epidemiologists. This initiative would have broad implications for the array of population surveys that are currently supported by NIA and fits into a broader NIH and Departmental concern with improving the measurement of the burden of illness. This initiative would have a specific focus on racial and ethnic minority populations and on capturing some of the variation in well being between and among populations.
Action Plan: Through analyses of the 1999 wave of the National Long-Term Care Survey, and other surveys such as the Longitudinal Study of Aging and the Health and Retirement Study, improve tracking of changing disability rates by race and ethnicity, understand causal determinants of changing disability rates, and search for ways to accelerate the disability decline among racial and ethnic minority populations.
Action Plan: Both the IOM report of a "paucity of research" on elder abuse and neglect (Violence in Families, 1998) and significant NIA supported research recently published in JAMA (Lachs MS, et al. 1998;280:428-432) demonstrate the devastating long-term consequences of elder mistreatment. Research is needed on the prevalence of elder abuse, interventions to reduce the incidence of elder abuse, and reliable measurement tools for assessing elder abuse by health care professionals. NIA will consider an NRC/IoM Panel to assess these issues, and if successful, will create a series of research initiatives to address abuse, neglect, and fraud with special emphasis on diverse populations. For example, do diverse ethnic/racial populations define abuse/neglect differently? Variability of definition in diverse groups will be emphasized in future efforts to resolve confusion about the variables of interest. Research on the impact of abuse, neglect, and fraud in diverse ethnic/race groups and the creation and testing of race/ethnicity sensitive interventions to prevent or ameliorate the impact of these events will be solicited.
A2. Develop new or improved approaches for detecting or diagnosing the onset or progression of disease and disability among older ethnic and racial minorities
Action Plan: The Alzheimer's Disease Cooperative Study (ADCS) is a consortium of over 30 sites across the U.S. set up to do clinical trials on Alzheimer's disease. From its inception in 1991, the ADCS has had a focus on recruitment of minority individuals, especially African-Americans and Hispanics. There is a minority recruitment core, the purpose of which is to improve minority participation in clinical trials by a variety of mechanisms and thus ensure that safety and efficacy of potential treatments are adequately evaluated for these groups. Meta-analysis of placebo groups will yield data on both normal and abnormal cognitive changes with age in different ethnic and racial groups. The ADCS has a mandate to develop new test instruments for evaluating the effects of drug interventions on the symptoms and course of AD. Most of the neuropsychological and clinical evaluation instruments used in ADCS clinical trials are translated into Spanish and are being used in ADCS trials for Spanish-speaking individuals.
Action Plan: The Baltimore Longitudinal Study of Aging has defined the time course for prostate specific antigen (PSA) in prostate cancer and hyperplasia in Caucasian men, and has demonstrated the usefulness of PSA for early diagnosis and as a risk factor for these diseases. These findings improve the ability to screen men for this disease and can identify men who are at higher risk of developing an aggressive cancer. By knowing early that a cancer is present, and by knowing its aggressiveness, men and their physicians can better plan appropriate strategies to deal with this potentially devastating disease. For men who are likely to have a less aggressive cancer, watchful waiting may be appropriate with intermittent evaluations to follow the progression of disease. We do not know how to best use longitudinal measures of PSA and prostate volume in assessing prostate cancer risk in African American men who have the highest rate of prostate cancer in the world and who have higher baseline PSA levels. Longitudinal collection of this data will better equip physicians to determine which strategies of screening and diagnosis are most appropriate.
Action Plan: Following an agenda setting conference, initiatives will be issued to suggest research on ethnic/race differences in the use of, processes associated with, and outcomes of various health care delivery systems and settings. Interventions for facilitating system access and use by a variety of minority groups will be emphasized. Additionally, these initiatives will include research on disparities in the use of various settings ancillary to the formal health care delivery system. These include research on minority and non-minority variability in the use of independent but age segregated housing, continuum of care retirement communities, assisted living facilities, PACE, and nursing homes.
Action Plan: The new potential initiative is titled " Health disparities in normal cognitive aging and Alzheimer’s disease." This is the first step in a multi-ethnic initiative. In an attempt to capitalize upon and expand current funded research efforts to establish neuropsychological test norms for African-American elders, we plan to first hold a conference to bring together investigators to discuss development of standardized measures of cognitive change in normal aging in multiple ethnic groups. Goals of the conference would include: establishment and appraisal of an inventory of currently available instruments; discussion of gaps that need to be filled and improvements that need to be made in order to achieve more valid and reliable norms for diverse groups; the multiplicity of factors to be considered when establishing culture-fair tests, including educational attainment, quality of education, gender, and degree of acculturation; barriers to overcome for implementation of both research and practice. Building upon the results of the conference, a standard set of measures for testing in diverse communities would be developed, tested and implemented.
Action Plan: NIA supports an ongoing portfolio of research on the impact of medical encounters on the health outcomes of older patients. A portion of this ongoing program will be focused on the impact of doctor-patient interactions on minority/ethnic populations. Minorities are often disadvantaged in terms of not having their chronic illnesses recognized as soon or treated as aggressively as the majority population. This is particularly critical in later life when illnesses are often more severe and health consequences catastrophic. Targeted studies are needed on the role of doctor-patient interactions as a key factor in explaining health disparities in diagnosis, treatment and management of chronic illnesses. This initiative will examine minority, SES, gender, and age differentials in the context, processes, and outcomes of health care encounters, in the development and testing of strategies for enhancing communications in older minority populations, and in the creation of new measures and methodologies for examining provider-older patient interactions in diverse populations.
A3. Develop new or improved approaches for preventing or delaying the onset or progression of disease and disability among older racial and ethnic minorities
To develop ways of preventing, delaying, and halting disease requires the contributions of many disciplines. Epidemiology can identify the magnitude, and possibly the variability, of a disease in different populations and may identify those at greatest risk. An understanding of disease mechanisms can produce means of preventing or delaying the onset of disease by determining the cause of a disease, how it affects cells or organs, or whether there is a genetic predisposition for the disease. Behavioral studies are important since intervention may require new medication or change in behavior. Clinical research and trials are the only means of evaluating new therapies or behavioral approaches. Remarkable progress is being made through basic, clinical, and epidemiologic research toward developing innovative, safe, and effective approaches to prevention and therapy for the population over age 65. The NIA has five continuing initiatives in this area. For additional initiatives relevant to this goal, please see Goals A1 and A2 under the research section.
Action Plan: Continue program activities at the NIA addressing cognitive function and aging, and personality and social psychological aging. Program initiatives and activities include interventions designed to improve cognitive or related perceptual abilities and skills that can reduce the need for formal care and hospitalization, and maintain independence for older people. Everyday tasks that use inductive reasoning can be taught by demonstrating strategies to identify rules or patterns or by practicing problem solving. Regular challenges of the brain can help retain cognitive abilities and mental acuity. Research with such practical applications for improving everyday functioning is encouraged.
Action Plan: Encourage the analysis of NIA supported longitudinal surveys, such as the Health and Retirement Study, National Long Term Care Survey, and Panel Study of Income Dynamics, to study how education affects health and cognitive functioning. Specifically encourage research using the minority over-samples of these surveys to study health disparities, including the application of analytic results to older adults with varying educational levels.
Action Plan: Relatively little is known about minority caregiving and most caregiving interventions have not included sufficient numbers of minorities to know how to best tailor interventions in order to help caregivers maintain their loved ones at home for as long as possible. As part of our AD preventive initiative, we are currently funding the Resources for Alzheimer's Caregiver Health (REACH) program, initial set of coordinated studies to examine the effects of psychoeducational support groups, behavioral skills training programs, family-based systems interventions, environmental modifications, and technological computer-based information services in over 1000 Caucasian, Hispanic, and African-American families in Alabama, California, Florida, Massachusetts, Pennsylvania, and Tennessee. A major outcome of this initiative will be the availability of a pooled database that will enable investigators to answer key questions about optimal intervention strategies for maintaining and improving the health and quality of life of caregivers of dementia patients.
Action Plan: Outreach will be made to community organizations to recruit older minority populations for cognitive intervention research and deliver the interventions in the community. Proposed research would target those cognitive abilities and personality dispositions that affect and are affected by health behaviors, provider-patient interactions, adherence, and associated health outcomes in older, minority populations.
A4. Develop new or improved approaches for treating disease and disability
New information on the underlying causes of and risk factors for diseases and disabilities are helping researchers develop interventions to delay onset, slow progression, and reduce the severity of disease and disability. Behavioral and social science findings are also being applied to develop strategies that promote health and prevent disease.
Action Plan: The research in this initiative includes a focus on burdens of care associated with Alzheimer's disease caregiving as well as research focused on older adults and health care organizations and social institutions. Studies targeted to enhancing healthy behavior in older racial and ethnic populations are a high priority. Efforts to reduce disparities through this research will include development of culturally appropriate screening tools and health care services, as well as means to enhance the likelihood of elders initiating and maintaining health promotion interventions.
Action Plan: The current NIA initiative on diversity in medication use and outcomes has focused on identifying minority differentials in medication use and prescription. Based on promising studies showing the potential of behavioral, environmental and technological interventions for improving medication use in younger, non-minority populations, we propose a set of targeted studies to investigate strategies for reducing medication errors and mismanagement in older, diverse populations. Randomized clinical trials testing viable medication "prompts" in diverse populations and new technologies for enhancing self-management in various settings (e.g., nursing homes and assisted living facilities) will be included. These research activities will be set within a broader initiative that includes the development and testing of culturally sensitive interventions to enhance self-management skills for common age-related chronic conditions such as diabetes, arthritis, or heart disease (e.g., strategies for increasing adherence to recommended pharmaceutical and behavioral regimens). As a related activity, consider enhancing existing longitudinal surveys, such as the National Long Term Care Survey, to collect data on medication use among the minority older population.
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