July 1996 Bulletin

Treating elderly is a team effort

Orthopaedists, geriatricians tackle growing problem

Orthopaedic surgeons and geriatricians are teaming up to respond to the needs of the growing population of elderly Americans.

Although the big surge in the elderly population is not expected until the baby boomers turn 65 in the next century, significant demographic shifts are already underway. In 1940 only 7 percent of Americans had a chance of living to age 90; in 1980, it was 24 percent. In 1950 there were 4,475 persons age 100 years or older; by 1990, the number was 54,000.

The American Geriatrics Society (AGS) anticipates that the rapidly growing elderly population will create a shortfall of as many as 31,000 geriatric clinicians by the year 2000. The organization also is aware that many surgical specialties are treating many elderly individuals who do not have family physicians or internists. Further, many surgical specialties do not devote significant amounts of training to geriatric education in their training programs.

In 1994, the AGS received a grant from the John A. Hartford Foundation for a three-year project on "Increasing Geriatric Expertise in Non-Primary Care Specialties." The AGS targeted five specialties-emergency medicine, general surgery, gynecology, orthopaedic surgery and urology-to encourage more geriatric training in their residency programs. Sixteen residency programs were selected to participate.

The department of orthopaedic surgery at the University of Pittsburgh Medical Center was among the residency programs that were selected to participate in the AGS program. Like others, representatives of the University of Pittsburgh Medical Center residency program visited a geriatric center to learn about training in geriatrics and to discuss ways to incorporate more of the training in their residency programs. In the second year of the program, directors of the geriatric centers visited the residency programs.

A multidisciplinary team was established at the medical center in April, said Harry E. Rubash, MD, associate professor and clinical vice chairman of the department of orthopaedic surgery. The Orthopaedic-Geriatric Service was made up of orthopaedic surgeons, geriatricians, physiatrists, rehabilitation experts, psychiatrists and others, as needed, said Dr. Rubash.

In making rounds of elderly patients, the team encounters typical conditions of elderly patients-multiple medical problems, delirium, depression, incontinence and poly-pharmacological problems. The team makes a functional assessment of the patients, identifies the problems, and develops the treatment, said Adele Towers, MD, a geriatrician on the team. The program includes weekly rounds and didactic lecture sessions.

It's a win-win situation for both patients and the team. The multidisciplinary approach improves the outcomes of patients, the orthopaedic surgeons are learning new skills in treating the elderly, and geriatricians are learning from the surgeons.

"As managed care takes over, it will be increasingly important to be efficient, have good outcomes, and be cost-effective," Dr. Towers said.

Equally enthusiastic about the AGS program is E. Dennis Lyne, MD, program director, orthopaedic surgery residency, Kalamazoo Center of Medical Studies, Michigan State University. Geriatric training has been built into four, two-hour lectures. "Now we need to implement a teaching rotation involving patients," Dr. Lyne said.

Mount Sinai Medical Center, N.Y., has developed an orthopaedic-geriatric program involving a multidisciplinary team of orthopaedic surgeons, geriatricians, nutritionists, social workers and physical and occupational therapists. The team approach provides better patient care, and also provides training in geriatrics for orthopaedic surgeons, said Myron Miller, MD, professor, department of geriatrics and adult development.

The team was assembled from the existing staff, but the hospital also
"enriched" the support with social workers and rehabilitation experts.

By tackling problems as a team rather than referring each problem to an individual expert, the team is able to develop a coordinated plan, implement treatment quicker and get good outcomes faster, Dr. Miller said.

The program is part of the orthopaedic service under the direction of Elton Strauss, MD, chief of orthopaedic training and reconstruction.

Dr. Strauss became interested in the geriatric aspects of medicine eight years ago when he saw the need for better care for his elderly grandfather. Dr. Strauss has learned a lot about treating the elderly.

"The elderly have more comorbidity than I thought they had, and they are sicker than they think they are," he said. "They have too many bottles of medicine, some causing psychiatric problems like depression and anxiety. They see too many different physicians; they see one doctor at the union medical center and another who is close to home, and don't communicate this to anyone.

"The elderly may have substandard housing, no heat or furniture, no one to help them with their laundry. They may not have seen a social worker in years."

When the orthopaedic surgeon sees an elderly person with a hip fracture, the physician may find the patient has a cataract, hearing problem, multiple medications, prostate problems and more.

An orthopaedic surgeon for 18 years, Dr. Strauss said that in the beginning he would see a patient with a hip fracture, "pin it and let someone else deal with the medical management of the patient." Today, he knows the good results that can be accomplished by the team approach.

He's learned a lot; so have the geriatricians, he said.

Members of the University of Pittsburgh Medical Center's orthopaedic-geriatric team at bedside of Susie Lumpkins, 75, are, from left, John Magnotta, MD; Debbie Rocker, RN; Adele Towers, MD; Jules Rosen, MD; Nicholas Soteranos, MD; James Williams, MD; and Jill McClain, RN.

Mount Sinai Medical Center orthopaedic-geriatric team with patient David Carr, center, are from left, Richard Frieden, MD; Marvin Gilbert, MD; Joe Kessler, MD; Elton Strauss, MD; and Bonnie Packer, social worker.

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