October 1995 Bulletin

Aging U.S. to challenge orthopaedists

Academy launches program to enhance special skills, training

The aging of America in the years ahead will present the health care delivery system and medical education with an unparalleled challenge.

The early years of the new century will find one out of five Americans are over age 65 and the ranks of those 85 and older growing the fastest of all age groups.

Special skills and training will be needed to manage the health care needs of older patients who, generally, are different than younger patients in how they present, the number of coexisting disorders and disabilities, their ability to participate in their medical problems, and their expectations about outcomes.

As the primary provider of treatments for musculoskeletal disorders, the demographic shift has special significance for orthopaedic surgeons.

New initiative

The Academy has responded to the challenge with a major new initiative in research, health policy, and education.

It may be hard to believe in today's youth-oriented society, but by the year 2020, the number of Americans age 65 and older will outnumber those age 14 to 24. The percentage of the population under age 35 may never again be as large as it is today. By 2030, more than 20 percent of the population will be age 65 and older and 12 percent of the elderly will be age 85 and older.

The numbers may hide an even bigger demographic shift, because they are the Census Bureau's middle series projections that may prove to be conservative.

The implication for orthopaedic surgeons is clear because musculoskeletal disorders are the second most common reason for people to visit a physician. The major causes for physician visits by the elderly are arthritis, osteoporosis, hip and wrist fractures from falls, and strokes. The result is decreased mobility which is anathema to the elderly person who wants to maintain his or her independence, does not want to be a burden on family members, and fears being institutionalized.

Maintain mobility

Joseph A. Buckwalter, MD, chairman of the Council on Research, told the August 26 Board of Directors meeting, that "if we are to realize the future, we must look at our specialty in a different way. The future is in maintaining the mobility of millions middle-aged and older people."

Dr. Buckwalter was presenting a report of the Task Force on Serving the Elderly Orthopaedic Patient, that was established following a Board of Directors workshop in March. The task force also includes representatives of the Council on Musculoskeletal Specialty Societies and the Council on Education.

The workshop featured a presentation by Kenneth Brummel-Smith, MD, a family physician with a CAQ in geriatric medicine, who discussed the special considerations needed in treating the elderly patient. Joseph Lane, MD, discussed new biological and pharmaceutical developments that are likely to facilitate profound changes in treatment of musculoskeletal diseases, particularly osteoarthritis.

The challenge faced by medical specialists will be in learning how to diagnose and treat elderly patients' problems, said Dr. Brummel-Smith. Physicians will be dealing with people who are experiencing intellectual failure, immobility, instability, incontinence, insomnia, and iatrogenic problems.

"At no other time in their lives are people more physiologically diverse as in old age," he said. "One elderly person may look frail, but be a champion swimmer with an excellent cardiovascular system, while another may appear to be in good condition, but be suffering from diabetes and hypertension.

"Physicians must learn how diseases present in older patients-the heart attack where there is no chest pain, the infection where there is no fever."

Physicians also must learn that the expectations of older people are not the same as those of younger patients. "The elderly emphasize functional capabilities, not dying," he said. "They do not want to live long lives of dependency on family or be institutionalized."

Shift focus

Dr. Brummel-Smith expects a shift in focus from medical care concerned with mortality to medical care that emphasizes functional capabilities.

He recalls an old joke in medicine that "the treatment was a success, but the patient went to the nursing home. Physicians may believe that a treatment was successful in reducing a patient's blood pressure, but what if the patient can't walk, can't think, and is incontinent?"

In reviewing the implications of the demographic shift, Dr. Brummel-Smith pointed out that the typical orthopaedic practice, serving both old and young patients, will likely change. In today's orthopaedic practice, about 25 percent of the patients are age 65 and older, and 15 percent are age 13 to 18 years.

But Census Bureau projections of the population growth show the 65-and-older group increasing rapidly from 33 million people today to 65 million in 2030, while the size of the 14-to-17 age group stays about the same.

Many of the baby boomers, the first of whom turn 50 years old on Jan. 1, 1996, may have devoted enormous energy to running 10K races, foraging at salad bars, and popping vitamins, but that may not have much of an impact on the number of physician visits by the elderly population.

In 1980, 15 percent of all physician visits were made by people 65 and older; in 2040, the percentage is expected to be 27 percent. Of that group, 15 percent will be 75 and older.

The promise of a healthy old age is illusive, Dr. Brummel-Smith said. Many of the elderly may be healthy, but the sheer size of the age group indicates more elderly than before will have medical disorders and disabilities. Arthritis, osteoporosis, cancer, neurological problems, and fractures caused by falls are inescapable problems for many of the elderly.

He pointed out that as the population gets older, the time period when they are disabled is extended and, therefore, the need for medical intervention increases.

Work with AGS

The Academy is working closely with the American Geriatrics Society (AGS) which has a $754,000 grant from the John A. Hartford Foundation in New York City for a program to increase geriatric expertise in non-primary care specialties.

The objectives are to improve the amount and quality of geriatric education received by residents in specialties dealing with the elderly, assist professional certifying bodies and specialty societies in improving the ability of their constituencies to care for elderly patients, and identify and support specialty faculty in promoting geriatric training and research within their professional disciplines.

The targeted disciplines are emergency medicine, general surgery, obstetrics/gynecology, orthopaedic surgery, and urology.

The AGS has made a grant to fund a symposium on geriatrics-related issues-"Orthopaedic Challenges in an Aging Population"-at the Academy's Annual Meeting and a grant to develop an educational curriculum for residents and practicing orthopaedic surgeons that focuses on care of the elderly patient.

The AGS points to a study by the Boston University School of Medicine that indicates few of the non-primary disciplines have any geriatric education or emphasis within their training program.

The AGS believes that by the year 2000 there will be a shortfall in meeting the needs for academic geriatricians and geriatrics clinicians. One method of attacking the problem is to increase geriatrics expertise in the non-primary care medical and surgical specialties.

In research laboratories across the country there are major research initiatives in molecular biology, bioengineering, and biomechanics that hold promise of improved treatments for the elderly in the future.

"I don't want to denigrate the research," said Dr. Brummel-Smith. "The advent of arthroscopic surgery is a tremendous benefit for the older patient, because it is less invasive than open surgery, and the research on cartilage cells and osteoarthritis is terrific, but we need to think in the short run. What do we do now?"

The recommendations of the Task Force on Serving the Elderly Orthopaedic Patient, which were approved by the Board in August, include research, health policy, and education initiatives.

The task force recommended increasing the number of public and private research studies related to improving the musculoskeletal health of older Americans and striving to increase the role of managed care companies in funding research on the musculoskeletal health of older Americans.

Develop positions

Health policy recommendations include developing a program in orthopaedic long-term and home care that would include position statements and persuasive documents on the role of orthopaedic surgeons in these fields, and the necessity for adequate funding of these patient care modalities.

Also, the Academy should expand its public education program to include resources on topics such as preventing falls, importance of exercise, geriatric athletes, and education of family members on providing care for elderly relatives. These materials should be developed in liaison with related organizations such as the AGS, National Institute on Aging, and American Association of Retired Persons.

In education, the task force urges effective publicity for the 1996 Annual Meeting symposium on "Orthopaedic Challenges of the Aging Population," directing the Scientific Program Committee to schedule a symposium on an aging-related topic for the 1997 meeting, and creating an exhibit on the challenges and opportunities facing orthopaedics related to an aging population and on the efforts of the Academy and the AGS to address them.

Also, the Committee on Instructional Courses should be directed to increase its offerings on issues related to an aging population and on geriatric orthopaedic problems. COMSS should educate its member societies on these issues and urge them to incorporate relevant educational offerings into the annual and Specialty Day meetings.

Other recommendations are to have the Committee on Educational Programming incorporate aging-related material into each of its comprehensive courses, at an appropriate level; direct the editor-in-chief of the Journal of the American Academy of Orthopaedic Surgeons: A Comprehensive Review to consider such topics and to add to the editorial advisory board a person, perhaps from outside the specialty, knowledgeable in the specific issues addressed by the joint task force. The committee also is urged to present the issues in Instructional Course Lecture volumes, monographs, a bibliography and Orthopaedics Knowledge Update 6.

A task force to develop a curriculum for resident education relating to geriatric patients and increasing the material related to geriatric orthopaedic patients in Orthopaedic In-Training Examinations also was recommended.

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