The population boom of older people is in full swing and will become explosive after 2011. Conservative assumptions predict growth of the population who are 65 years and older in the United States from 35 million in 2000 to 78 million in 2050 (from 13–20% of the population), and growth of the population who are 85 years and older from 4 million to 18.2 million.13 Moreover, if we assume life expectancy from 65 years will continue to increase at the rate seen in the 1990s, then the projected population of people 85 years and older would reach 31.2 million by the year 2050.14 Because of improvements in skill and technology in the various surgical and medical specialties, and better physiologic status of older adults, there has been and will be a disproportionate increase in the proportion of persons 65 years and older who are candidates for surgery and other surgical and medical interventions.7
New challenges will be presented to the healthcare delivery system as the growth in numbers and proportions of older people increases sharply in the coming decades. Orthopaedic surgeons will see more seniors with musculoskeletal disabilities that will threaten their function, independence, and longevity. Healthy lifestyles and quality of life will be compromised unless specific treatment pathways and education begin to focus on these issues.
Increasing age leads to degeneration of the musculoskeletal system. By the year 2020, approximately 20% or an estimated 50 million people will be older than 65 years.15 Approximately 80% of those individuals will have musculoskeletal complaints. Fractures, arthritic joints, degenerative spine disease, osteoporotic deformities and injuries, pathologic fractures, and soft tissue manifestations such as rotator cuff disease will increase patient-physician visits and surgical interventions.
Approximately 350,000 hip fractures occur annually. This number is expected to double by 2050. Currently, the cost in medical bills and lost earnings from hip fractures is more than $9.8 billion a year, or an average of $35,000 per hip fracture.1 Eighty-seven percent are among persons 65 years and older.1 The aging of Baby Boomers, who may be caring for a parent with a broken hip, also is dangerous because the incidence of hip fractures starts to increase at an early age. Mortality studies reveal that 7–27% of patients with hip fractures die within 3 months after injury because of complications related to the injury and the recovery period.3 This fracture spectrum is of concern even though technology of fixation has improved.
Most patients with hip fractures who previously lived independently will require assistance from their family or home care. Approximately ½ will require canes or walkers for mobility when they return home, for life. Forty percent of patients with hip fractures who are 65 years and older are discharged from hospitals to long-term care facilities for the remainder of their lives.2
Forty percent to 60% of older individuals will report significant OA of the lower extremity. Disabling OA of the weightbearing joints frequently leads to joint replacement surgery, done an average 648,000 times annually from 1993 to 1995.8 In 1996, 74% of TKAs and 68% of THAs were done on patients 65 years and older.8 Joint replacement is expected to increase by at least 80% by 2030.8
Age-related changes in bone and soft tissue frequently are associated with disabling fractures. In the first 5 years after menopause, women can lose as much as 25% of their bone mass. Osteoporosis affects approximately 20 million Americans, and every year 1.3 million fractures are attributed to osteoporosis. Muscle strength decreases by approximately ⅓ after the age of 60 years, which can lead to difficulty maintaining balance and predispose to falling. The cost of treating all osteoporotic fractures was estimated to be $13.8 billion in 1995 and is expected to double in the next 50 years. Most of this cost can be attributed to the treatment and postoperative care of patients with hip fractures.8
Geriatricians continue to be in short supply. Currently there are approximately 9000, whereas estimates of the need are approximately 30,000.11 The shortage of academic geriatricians particularly is pressing. In addition to playing a role in primary care, rehabilitation, and long-term care of elders, geriatricians offer expertise in pulling older patients through traumatic events and avoiding postoperative and other disasters that often befall elderly patients during hospitalizations.
Multidisciplinary integrated teams of healthcare personnel first were promoted by Boyd et al4 and later shown effective by Devas.6 This unit set policy, dedicated aims, maintained constant treatment, and developed methods of assessment. Since then most studies have documented fewer complications, fewer transfers to intensive care units, improved ability to walk, and fewer transfers to nursing homes.9,12 Reid and Kennie10 reported 41% of patients were discharged to home and these patients had a reduction in hospital stay of 10–32%. Zuckerman et al16 reported a similar correlation and concluded that this group of patients has specific and unique needs. Orthogeriatrics teams are successful and needed. Nursing home discharge should not be the key dominator for emptying beds and decreasing length of stay at the sacrifice of the patient.
Being a senior citizen should not be a requisite for being sedentary. Inactive older persons have a much higher risk of functional dependence than physically active, fit older persons. One study showed that physically active seniors live longer and healthier lives.5 Exercise regimes after surgery and even in patients in nursing homes have improved quality of life, activities of daily living, and decreased morbidities related to hypertension, diabetes, and falls.
The American Academy of Orthopaedic Surgeons created a Committee on Aging to increase awareness of these problems and to improve the quality of aging through programs and information. As a committee, we are concerned with the challenges of aging and the size of the epidemic. Among the concerns are musculoskeletal function housing, issues of diversitydifferences, transportation, medication costs, and insurance coverage. We think the goal for medicine in America should be the excellent care for every senior citizen, support for improved quality of care, and life at a cost that is effective. It is imperative to recognize the complexity of this group of patients and support them with the most comprehensive management regimes.
The aging epidemic is to be recognized as a problem of society with resources directed to successful treatment. This symposium highlights many of these issues and brings forward many of the surgical advances and adjuncts that will make care more successful. Awareness of the problem hopefully will ignite continued educational processes and a strong commitment to improve the care of this select group.
Elton Strauss, MD
New York, NY
1. Agency for Health Care Policy and Research DoHaHS. Inpatient Hospital Statistics, 1966. (Publication no. 99-0034), Rockville, Maryland: Agency for Health Care Policy and Research, 1999.
4. Boyd RV, Hawthorne J, Wallace WA, et al. The Nottingham Orthogeriatrics unit after 1000 admissions. Injury
5. Butler RN, Davis R, Lewis CB, et al. Physical fitness: benefits of exercise for the older patient. Geriatrics
6. Devas MB. Geriatric Orthopaedics. London, Academic Press 1977.
7. Francis J. Perioperative Management of the Older Patient: In Hazzard WR, Andres R, Bieman EL, Blass, JP. Principles of Geriatric Medicine and Gerontology. Ed 4th. New York, McGraw-Hill, page 365, 1999.
8. Praemer A, Furner S, Rice D. Musculoskeletal Conditions in the United States. Ed 2. Rosemont, IL, American Academy of Orthopaedic Surgeons 1999.
9. Radke MS, Flynn JP, Smith M, et al. Functional improvement in geriatric trauma patients admitted to a dedicated rehabilitation hospital. Md Med J
10. Reid J, Kennie DC. Geriatric rehabilitative care after fractures of the proximal femur: one-year follow-up of a randomized clinical trial. BMJ
11. Reuben DB, Bradley TB, Zwanziger J, et al. The critical shortage of geriatric faculty. J Am Geriatric Soc
12. Sainsbury R, Gillespie WJ, Armour PC, et al. An orthopaedic geriatric rehabilitation unit: the first two years experience. NZ Med J
13. United States Census Bureau. Statistical Abstract of the United States 1998. The National Data Book. Washington: page 4 Sept. 16, 1998.
14. United States Census Bureau. Statistical Abstract of the United States 1998. The National Data Book. Washington: page 5 Sept. 16, 1998.
16. Zuckerman JD, Sakales SR, Fabian DR, et al. Hip fractures in geriatric patients: Results of an interdisciplinary hospital care program. Clin Orthop