TERNOPIL STATE MEDICAL UNIVERSITY

INSTITUTE OF NURSING

INTERNATIONAL NURSING SCHOOL

 

Health Needs of Older Adults

Upon mastery of this chapter, you should be able to:

Provide an example of primary, secondary, and tertiary prevention practices among the older population.

● Identify and depict nutrition needs of older adults.

● Identify exercise needs of older adults.

● Identify and describe economic security needs of older adults.

● Identify and describe psychosocial needs of older adults.

·        Coping With Multiple Losses

·        Maintaining Independence

·        Social Interaction, Companionship, and Purpose

·        Safety Needs

● Spirituality, Advance Directives, and Preparing for Death

Effective nursing in any population requires familiarity with that group’s health problems and needs. Aging in and of itself is not a health problem. Rather, aging is a normal, irreversible physiologic process. Its pace, however, can sometimes be delayed, as researchers are discovering, and many of the problems associated with aging can be prevented (Menzey, 2001). The aging process is subtle, gradual, and lifelong. One can see remarkable differences among individuals in the rate of aging. Even in a single individual, various systems of the body age differently (Eliopoulos, 2001).

multiple, chronic, and often disabling conditions.

 

The elderly, like any age group, have certain basic needs: physiologic and safety needs as well as the needs for love and belonging, self-esteem, and self-actualization. Their physical, emotional, and social needs are complex and interrelated. The following sections discuss these needs according to primary, secondary, and tertiary prevention activities.

 

Primary Prevention

 

As discussed previously in this text, primary prevention activities involve those actions that keep one healthy. Such primary prevention activities as health education, follow-through of sound personal health practices, and maintenance of an appropriate immunization schedule ensure that older adults are doing all that they can to maintain their health. The list in Display 30–2 includes strategies for successful aging. Taken from a variety of sources, it provides primary prevention activites the community health nurse can use when working with elders, either individually or in groups.

 

Nutrition Needs

 

People who have maintained sound dietary habits throughout life have little need to change in old age. Many have not established such habits but may wish to. It is generally believed

 

Most people can keep their teeth for a lifetime with optimal personal, professional, and population-based preventive practices. Yet, in 1997, 26% of adults age 65 to 74 years had had all their teeth extracted. The Healthy People 2010 target is to reduce this number to 20% (USDHHS, 2000). Since the 1960s, water supplies and toothpastes have been fluoridated, and regular dental care has become more accessible and acceptable to most people. These measures have helped prevent periodontal disease, a major component of tooth loss in adults. Oral health and hygiene needs do not decrease with age. Eating, chewing, and swallowing should be an uncomplicated and natural process. Frequently, older adults are taking medications that cause dry mouth, taste alterations, and loss of appetite that limit the desire for food. Eating should remain a pleasurable social experience, preferably taking place in the company of others. Community health nurses can assist older adults with meal management by following the suggestions outlined in Display 30–3.

In addition to maintaining a healthy diet, older adults should avoid the habitual use of laxatives, instead adding more fiber and bulk to their diet. Inadequate fluid intake often contributes to bowel and bladder problems. Consuming a diet that includes six to eight 8-oz glasses of fluid (water, juices, tea) each day assists the gastrointestinal and genitourinary system in their functions. Also, more exercise helps keep an older adult’s bowel patterns regular.

AGE-FRIENDLY PRIMARY HEALTH CARE CENTRES TOOLKIT

Basics of nutrition counselling

1. Regularly weight and measure every patient. Advise them on their healthy weight range based on age, gender and distribution of body fat.

2. Talk with all patients about their dietary habits, including use of dietary supplements.

Use a brief nutritional screening questionnaire accepted in your country if available to identify nutritional vulnerability, or consider an evidence-based tool. (Green, S.M. and Watson, R. (2006) Nutritional screening and assessment tools for older adults: Literature review. Journal of Advanced Nursing, 54, (4), 47-490

While nutritional vulnerability is often associated with under nutrition, the prevalence of obesity is increasing among older persons, with potential health risks.

3. Provide basic information about managing a healthy diet. Use dietary guidelines of your country if available.

USA dietary guidelines

4. Use the following Food Guide Pyramid as an educational tool for planning healthful diet.

Food Guide Pyramid

Eating right from bottom to top in people aged 70 and older

Source: A food guide for older adults, Human Nutrition Research Center on Aging, Tufts University, USA, 2000

5. For women, recommend special dietarian particularly for calcium. Counsel older women to consume adequate calcium, which helps in:

• building optimal bone after menopause,

• controlling bone loss and delay development of osteoporosis.

Dairy products are major sources of calcium. Other sources of calcium are canned fish with soft bones, vegetables such as broccoli and spinach, and fortified cereals and grains.

Optimal calcium requirements recommended

6. For overweight patients, recommend:

a diet with fewer total calories from fat,

a modest increase in physical activity. See information on physical activity counselling.

In general, the goal should be a weight loss of 1 / 2 to 1 pound per week. Behaviour therapy and physical activity have been shown to help maintain weight loss.

7. Ongoing support and reinforcement to patients undertaking significant dietary changes.

This support can take several forms, including

follow-up visits,

telephone calls and postcards.

Recommend making changes gradually, in small, achievable steps over time. Encourage patients through the plateaus and regressions that occur as a normal part of efforts at longterm change.

8. Refer if necessary: patients with multiple or severe nutritional problems should benefit from a nutrition professional counselling as possible.

 

Exercise Needs

 

Older adults need to exercise; in fact, they thrive when exercise is incorporated into their daily routine. Research shows that exercise can slow the loss of bone density and increase the size and strength of muscles, including the heart (Kressig & Echt, 2002; USDHHS, 2000). Aging does not and should not involve passivity; instead, physical activity and movement contribute to the quality of intellectual and physical performance in old age. Exercise, such as a daily walk, can keep muscles in good tone, enhance circulation, and promote mental health. Exercise may occur in connection with such activities as homemaking chores, gardening, hobbies, or recreation and sports. Often, such physical outlets are enjoyed in the company of other people, meeting social and emotional needs as well as physical ones. Preparing for exercise by warming up helps to keep muscles free from injury and to prevent falls (American Institute for Cancer Research, 2002). Even among the very old, an exercise routine that includes activities that improve strength, flexibility, and coordination may indirectly, but effectively, decrease the incidence of osteoporotic fractures by lessening the likelihood of falling (Burbank & Riebe,

 

AGE-FRIENDLY PRIMARY HEALTH CARE CENTRES TOOLKIT

Basics of physical activity counselling

1. Evaluation of patients' usual physical activity

o Ask all patients about their physical activity habits. Include organized activities, general activities and occupational activities.

o Determine if the patient's level of activity is sufficient using the following physical activity pyramid. Experts agree that physical activity that is at least of moderate intensity, for 30 minutes or longer, and performed on most days of the week is sufficient to confer health benefits.

Tell patients, as doing the moderate-intensity physical activity, they will feel faster heart rate, faster breathing and slightly warmer.

Physical activity pyramid

* Avoid sedentary lifestyle such as watching TV or sitting in front of a computer for many hours a day.

Source: Rauramaa, R. & Leon, A.S. Physical Activity and risk of cardiovascular disease in middle aged individuals. Sports Medicine. 1996, 22(2):65-69.

2. Assist patients who lack sufficient physical activity for health benefits and/or wish to improve physical activity habits in planning a programme that should be:

• Medically Safe: Existing heart disease presents the biggest risk.

o Medical Evaluation: recommended prior to embarking on a vigorous exercise programme for the following individuals:

_ persons with cardiovascular disease (CVD);

_ men over 40 years and women over 50 years of age with multiple CVD risk factors – hypertension, diabetes, elevated cholesterol, current smoker, or obesity.

o Additional advice to promote medically safe physical activity includes:

_ increase the level of exercise gradually rather than abruptly,

_ decrease the risk of musculoskeletal injuries by performing alternate-day exercises and using stretching exercises in the warm-up and cool-down phases of exercise sessions. This is particularly important for older adults and those who have not been physically active recently.

• Enjoyable: Patients will not continue activities that they do not enjoy.

o They should:

_ choose activities they find inherently pleasurable,

_ vary activities,

_ share activities with friends or family.

o Encourage patients to identify barriers to enjoyment and to find ways to overcome these barriers. Examples of methods for overcoming barriers are listed in the next table:

Table 1. Overcoming barriers to exercise

• Convenient: Encourage participation in activities that can be enjoyed with a minimum of special preparation, ideally those that fit into daily activities.

• Realistic: A too difficult programme in terms of goals and integration with other daily activities will lead to disappointment. Gradual change leads to permanent change; therefore, stress the importance of gradually increasing the intensity, frequency and duration of exercise.

• Structured: Having defined activities, goals for performance and a set schedule and location may help improve some patients' compliance. Signing a physical activity "contract"/"action plan" may be helpful.

3. Encourage patients who are unwilling or unable to participate in a regular exercise programme to increase the amount of physical activity in their daily lives:

o taking the stairs rather than the elevator when possible,

o leaving the subway or bus one or two stops early and walking the rest of the way,

o doing household chores and yard work on a regular basis.

4. Involve nursing and office staff in monitoring patient progress and providing information and support to patients. Some form of routine follow-up with patients about their progress is very helpful.

5. Convey positive messages about exercise and physical activity using posters, displays, videotapes, and other resources in offices or clinics.

6. Providers should try to engage in adequate physical activity themselves. Studies show that providers who exercise regularly are significantly better at providing exercise counselling to their patients than those who do not.

 

 

Economic Security Needs

 

Economic security is another major need for older adults. Worrying about finances is often one of the most debilitating factors in old age. Fearing the potential costs of major illness and not wanting to be a burden on family or friends, many older people conserve their limited finances by establishing frugal eating patterns, using health resources sparingly, taking medications in partial doses, and spending little on themselves. Too often, the fear—let alone the reality—of financial difficulties prevents older adults from leading full and active lives.

 

For older adults today who have lived many years past retirement and perhaps had not planned for sufficient financial security to maintain them throughout these additional, unexpected years, the fears are not unfounded. Putting older people in touch with appropriate community resources can do much to relieve the source of that stress and anxiety. The community health nurse can also help younger, working adults plan for a physically and emotionally, as well as financially, vigorous old age.

 

Psychosocial Needs

 

All human beings have psychosocial needs that must be met for their lives to be rich and fulfilling. Without healthy relationships with other people, life can be very lonely and lacking in quality. With advancing age, the psychosocial issues are many. A major issue is coping with multiple losses. In addition, maintaining independence, social interaction, companionship, and purpose is necessary for a healthy old age. Older adults who have maintained good health and have developed a supportive system of family and friends have more fulfilled lives.

 

Coping With Multiple Losses

 

Elders experience multiple losses, including loss of income and prestige from a career once practiced or the economic stability of an enjoyable job; loss of space due to replacement of a larger residence by a much smaller home or apartment; and reductions in health and vitality that may result in limited movement or pain as a daily concern or necessitate another move to a more dependent setting. Repetitive losses occur as significant others, relatives, friends, and acquaintances die (Worden, 2002).

 

Inadequate coping with the compounding losses can make an older person believe that life holds no meaning. Depression may be a difficult problem for older adults. Social and emotional withdrawal can often occur, as can suicide. Although older populations have a much lower rate of suicide attempts than younger age groups do, the rate of completed suicide is high. It is highest among elderly men, who account for about 80% of suicides among those age 65 years and older. Moreover, elderly white men have a suicide rate six times the national average (USDHHS, 2000). Concern for the increased suicide rates among older white men led to a key health objective in Healthy People 2000: to reduce the suicide rate to

38.9 per 100,000 people, from the 1987 baseline of 46.1 per 100,000 (USDHHS, 1991). By 1997, for white men aged 65 years or older, the suicide rate was 35.5 per 100,000, exceeding the 2000 goal. Suicide continues to be of concern and is included in the Healthy People 2010 objectives. Because most elderly persons who commit suicide have visited their primary care provider in the last month of their lives, recognition and treatment of depression in health care settings is a promising way to prevent suicide in this age group.

Mortality after bereavement is high and can be prevented through nursing intervention. Loss and the mourning process among elders have been examined in many studies. It has been found that the ability to mourn prior states of one’s self and the past is crucial to successful aging. This can be liberating and can provide energy for current living, including planning for the future (Worden, 2002). Although men and women experience similar levels of depression dur ing early bereavement, it is more difficult for widowers to seek and receive social support. Higher levels of perceived social support are associated with lower levels of depression in widows and widowers (Moore & Stratton, 2002). In addition, more men than women die soon after the death of their spouses. Women have stronger social support systems throughout their lives, and these help sustain them during losses in old age (Moore & Stratton, 2002).

 

In addition to preventing early deaths after the loss of a spouse, the greater goal for the nurse in promoting successful aging can be accomplished when the nurse recognizes the significance of accepting all the losses of aging. The loss of a spouse is much more frequent for women than for men (Eliopoulos, 2001). With this knowledge, a woman can age successfully by planning for the future through anticipatory guidance, with the help of a community health nurse. Many women can expect to live alone for up to 20 years at the end of their life, because of a longer life expectancy and the fact that women in most cultures marry men older than themselves. The nurse can help to make these years meaningful and as healthy as possible.

 

 

Maintaining Independence

 

Older people need independence, and those who stay independent are happier. As much as possible, the elderly need to make their own decisions and manage their own lives. Even those with activity limitations because of disability can still exercise decision-making options about many, if not most, aspects of their daily living. The need for autonomy—to be able to assert oneself as a separate individual—is great for all people. With life’s restrictions ever increasing for the elderly person, this need is all the greater (Eliopoulos, 2001). Independence helps to meet the need for self-respect and dignity. The elderly need to have their ideas and suggestions heard and acted on and to be addressed by their preferred names in a respectful tone of voice. Respect for the older adult is not a strong value in American society, but it is highly valued in Asian, Italian, Hispanic, and Native American cultures. Older people represent a rich resource of wisdom, experience, and patience that is generally wasted in the United States.

 

Social Interaction, Companionship, and Purpose

 

Older people need companionship and social interaction, particularly if they live alone. The company of other people and the companionship of a household pet offer avenues for expression and response and add meaning to life. Many studies of mortality patterns demonstrate that older adults living together have a greater survival rate and retain their independence longer than do those who live alone (Miller, 1999).

 

 

The problem is of greatest significance for women, who outnumber men considerably in the later years and who live alone more frequently.

 

It is also important for older adults without companions to discover and develop a friendship with someone who can be considered a confidant, someone in whom the older adult can confide, reflect on the past, and trust. It could be a close friend, a sibling, a son or daughter, or an acquaintance. This person is usually seen daily or talked with on the telephone each week. In particular, mothers and daughters form confidant bonds. Many women consider a sibling a confidant, especially if that person lives close by; this is especially true for childless and single women.

 

Meaningful activity is another need of the elderly that adds purpose to life. Some kind of active role in community life is essential for mental health, satisfaction, and self-esteem. These activities can range from involvement in hobbies, such as gardening or crafts, to volunteer work or even full-time employment. Examples include the federally supported Foster Grandparents and Senior Companions programs, which engage the help of more than 20,000 seniors. These older adults work part-time offering companionship and guidance to handicapped children, the terminally ill, and other people in need. Senior Partners is another program that keeps older adults involved. Volunteers earn service credits by providing support services so that persons age 60 years or older can remain independent and active in their own homes. Each hour of volunteer service earns one service credit. Credits may be “spent” in several ways. They can be used to obtain services, should the volunteer need them, or they can be donated to another person in need or donated back to Senior Partners to help others.

Additional volunteering opportunities abound. Internationally, many older professionals join the Peace Corps, which was initiated in the early 1960s. In this program, people of all ages work for 2-year periods in global communities that are in need of services to improve personal health, education, environment, and the larger community. On the national level, the newer AmeriCorps*VISTA (Volunteers in Service to America) programs are similar, but with a 1-year commitment; the volunteer lives among and at the economic level of the low-income people in the United States served by its projects. Retired people can volunteer to help others, donating their skills at a time in their lives when they are in transition from employment to retirement or to fill active retirement years. The Retired and Senior Volunteer Program (RSVP) engages seniors in a bevy of activities designed to improve people’s lives and the environment. Environmental Alliance for Senior Involvement (EASI) sponsors various environmentally focused programs, such as assisting the Hawk Mountain Sanctuary to protect birds of prey or monitoring streams and other waterways for cleanliness.

 

Many older adults choose not to engage in long-term volunteering, and other programs are more appropriate for them. Elderhostel, Inc., is a nonprofit organization with more than 25 years of experience providing high-quality, afford able, educational adventures for adults who are 55 years of age and older. It is the nation’s first and the world’s largest education and travel organization for adults age 55 and over, offering more than 10,000 learning adventures each year in more than 100 countries. Their theme-based, short-term (3 days to 3 weeks) educational programs are infused with a spirit of camaraderie and adventure (Elderhostel, 2002). In 2002, even when many others were limiting their travel, more than 175,000 adults took advantage of the unique experiences that Elderhostel has to offer. The success of this program is based on the fact that learning is a lifelong process that is rewarding at any age, and it is learning without testing or papers due! Elderhostel is inspired by the youth hostels and folk schools of Europe but guided by the needs and interests of older citizens.

 

Safety Needs

 

People of all ages have safety needs, and this concept has been threaded throughout the five chapters in this unit on developmental needs of clients. Likewise, safety issues are a major concern for older adults and the community health nurses who work with them. Several areas of safety focus are discussed here: personal health and safety, home safety, and community safety.

 

Personal health and safety include three major areas: immunizations, prevention of falls, and drug safety. Immunizations are not just for children. Older adults are at risk for not only contracting influenza or pneumonia but dying from them. Pneumococcal disease, influenza, and hepatitis B account for more than 45,000 deaths annually, mostly among older adults. Ninety percent of influenza-related deaths occur in people age 65 years and older (USDHHS, 2000). Although the overall influenza immunization rate among elders has increased, from 33% in 1989 to 63% in 1997, and pneumonococcal vaccine coverage rates have increased from 15% to 43%, improvement is still needed. Despite the increases, coverage rates for certain racial and ethnic groups remain substantially below that of the general population. For example, the influenza vaccination rate for whites was 66% in 1997, whereas for African-Americans it was 45% and for Hispanics it was 53%. In September of 1997, the USDHHS approved an agency-wide plan to improve adult immunization rates and reduce disparities among racial and ethnic minorities through their “Put Prevention Into Practice” program, a national campaign to improve delivery of clinical preventive services (USDHHS, 2000). Attempts to improve immunization coverage involve changing provider knowledge, attitudes, and behavior through reminders and standing orders so that “missed opportunities” when seeing clients are prevented. Additional opportunities for vaccinating people exist beyond the primary care setting, as community health nurses are well aware. People can be reached during emergency department visits, at neighborhood and senior centers, at religious facilities, and in other innovative settings where elders may gather. Regardless of the site, a method for tracking and communicating vaccinations is needed so that vaccination information may be documented and shared with the elder’s primary care provider. Immunizations protect more than the at-risk population—they protect society as a whole. People of any age with a chronic illness, such as heart disease, diabetes, or chronic respiratory disease, and people older than 65 years of age should be encouraged to receive the flu vaccine each year and the pneumonia vaccine every 5 years.

Each year, approximately one third of people older than 65 years of age who are independent and living on their own experience a fall; for those individuals residing in long-term care settings, the percentage is 50% (Hill-Westmoreland, Soeken, & Spellbring, 2002). Every year in the United States, 300,000 people are treated for hip fractures, 90% of which are caused by falls (Jech, 2000). Causative factors involve both environmental hazards and host issues. Fall prevention, which involves education, strengthening and balance exercises, medication evaluation, and environmental improvements, is an important part of the role of the community health nurse. Use of a home safety checklist can give the nurse a baseline of information from which to begin teaching (Display 30–4).

For more information go to Elderly Safety, Home Safety for the Elderly.

A significant safety issue for the older adult arises from adverse drug effects. Older people may need to take several medications to control the effects of chronic conditions, and their bodies may react differently than those of younger people (on whom most new drugs are tested). It is not unusual for older people to be taking four to six medications daily and filling 13 prescriptions each year. It is estimated that 25% of all older people who live independently receive prescriptions for inappropriate medications (Jech, 2000). Elders receive multiple prescriptions from multiple providers and are in danger of receiving double doses of the same or similar medications. Multiple medications or complicated drug regimens for many older people can lead to unexpected and dangerous drug interactions. The use of more than four prescribed medications is related to an increased risk of falling (Jech, 2000). Elderly clients need education about the drugs they take and their possible effects. They also need proper supervision of their overall medication intake. This is an area in which the community health nurse can intervene very effectively and with much success.

 

Safety in the community is an additional concern. Safety involves pedestrian and driving issues, crime and fear of crime against elders, and environmental factors such as sun exposure, pollution, heat, and cold.

 

Because of age-related changes in vision, hearing, mobility, and the effects of polypharmacy, elders are at risk in the community as pedestrians and as drivers. Automobile crashes and pedestrian injuries can be life-threatening events when elders are involved. As pedestrians, elders must be increasingly vigilant to traffic patterns, sidewalk irregularities, and the possibility of being a victim of street crime. Often out of necessity and pride, elders drive longer than their abilities permit. In 1998, 23.7 of every 100,000 older adults died of motor vehicle-related injuries. Only the 15- to 24-year-old population had a higher rate (National Center for Health Statistics, 2002). All traffic and pedestrian fatality rates are higher in this age group. On the basis of estimated annual travel, the fatality rate for drivers age 85 years and older is 9 times as high as the rate for drivers 25 through 69 years of age, with a 31.5 deaths per 100,000 people (U. S. Department of Transportation, 1998). To stop driving is usually a difficult and painful decision for the elder to make. At times, the car keys may have to be taken from the elder, for his or her own safety and that of others. This may be necessary especially with elders who have dementia, AD, uncorrectable vision problems, or stroke-related physical or cognitive after-effects.

 

Actual crime against elders in the community is as much as 50% lower than among other segments of the population. However, the fear of crime among elders is perceived as a major issue by the general public, and about 25% of elders consider the fear of crime a major concern. Display 30–5 lists client-centered nursing interventions designed to reduce fear among older adults and empower them to feel safer in their communities.

 

Environmental factors can have an effect on the health and safety of elders when they are outside. Sun exposure, pollution, and exposure to heat and cold can have negative effects on older adults. They are just as vulnerable as infants and children to climatic changes and should take a variety of preventive measures, including using sun block when gardening, reading, or walking outside for longer than 10 minutes, even on days with an overcast sky; staying indoors on days when the air quality is poor or there is an air safety alert; drinking additional fluids, wearing protective covering, and limiting outdoor activities and exposure on days with elevated temperatures; and, conversely, limiting outdoor exposure and wearing appropriate winter clothing, especially layers of clothes, on cold, snowy, or icy days. Teaching geographically and seasonally appropriate safety precautions is the responsibility of the community health nurse providing services to groups of elders in the community.

 

Spirituality, Advance Directives, and Preparing for Death

 

A final need of the elderly, and one that is receiving increasing attention, is that of preparing for a dignified death. Elisabeth Kubler-Ross (1975) described death as the final stage of growth and one that deserves the same measure of quality as other stages of life. Many older people fear death as an experience of pain, humiliation, discomfort, or financial concern for their loved ones. Planning for a dignified death is an important issue for many older people. For most, this includes choosing, if possible, where and under what circumstances death will occur; being free of financial worries; knowing that their affairs and their family members are taken care of; having the opportunity to receive spiritual counseling; and dying in peaceful surroundings, preferably at home with the support of loved ones (Cicirelli, 2002; O’Brien, 2003).

 

Some elders make arrangements with a funeral home of their choice, selecting interment or cremation, a memorial service or a celebration of life gathering, music to be played, and other personal details rather than leaving these choices to their families. Others place less emphasis on the rituals, as was demonstrated by one elder who left these choices to her children by telling them, “Surprise me!”

 

 

 

 

Living wills and medical directives are legal documents whose purpose is to give people legal power over the medical treatment they would want if they became incapacitated or terminally ill. Living wills are legal in all states and the District of Columbia (Miller, 1999). Having such documents prepared and made known to significant others can ensure that the older adult’s wishes will be honored.

 

Additional readings:

Age-friendly Primary Health Care Centres TOOLKIT // World Health Organization, 2008.

Bell, V., & Troxel, D. (2001). The Best Friends staff: Building a culture of care in Alzheimer’s programs. Baltimore: Health Professions Press.

Burbank, P.M. & Riebe, D. (2002). Promoting exercise and behavior change in older adults: Interventions with the transtheoretical model. New York: Springer.

Cicirelli, V.G. (2002). Older adults’ views on death. New York: Springer.

Ebersole, P., & Hess, P. (2004). Toward healthy aging (6th ed.). St. Louis: Mosby.

 

WEB SITES on Aging

American Diabetes Association, Facts and Figures: http://www.diabetes.org

Assisted Living Federation of America http://www.alfa.org

National Institute on Aging. http://www.nia.nih.gov