Care of the elderly has reached a virtual “perfect storm” of concern in the ongoing healthcare debate. Multiple forces have converged to sharpen our collective focus on this issue. First of all, the “baby boom” generation is approaching their elder years in an age of great medical advances. During the 20th century, the average lifespan in the United States increased by more than 30 years, of which 25 years can be attributed to advances in public health. Elderly persons represent the fastest growing segment of the population. It is projected that the number of citizens older than 75 years will quadruple in the next 50 years.

 

Greeting this aging population is a remarkable advance in medical technology, and nowhere is this more apparent than in the field of heart disease, which despite a progressive decline in mortality rate, has remained the leading killer of men and women in this country for the past half century. Nearly 40% of octogenarians have symptomatic cardiovascular disease, which accounts for more than half of the mortality in this age group. Cardiac surgery, which 25 years ago was reported to carry a mortality approaching 30% in octogenarian patients, has more recently been reported to carry a mortality a fraction of that and comparable to that of the younger population. Technology has facilitated the evolution of minimally invasive less morbid surgical approaches. Innovative interventional techniques which can be performed without surgical incisions or anesthesia, using catheters inserted from the leg or arm, have replaced the need for surgery in many instances. Most recently, this catheter-based approach has been successfully applied to the replacement of intracardiac valves in selected patients, obviating the need for an open heart surgical procedure. These advances, along with an acceleration of knowledge in the most appropriate care of critically ill patients has broadened the indications for which medical interventions can and should be applied.

 

All of this demographic shift and medical advance brings us to the third element compelling our attention – cost. Medicare, the health insurance program for the elderly, spends nearly 30 percent of its budget on beneficiaries in their final year of life. Moreover, Medicare and Medicaid represent a growing proportion of an increasingly challenged federal budget. Medicine of the twentieth century was the medicine of the possible – the driving question was, what can we do? Medicine of the twenty-first century, of necessity, needs to be the more sober medicine of the appropriate. No longer is the question what can we do, but rather, what should we do? These decisions are difficult and require a societal consensus. Certainly, at present, no such consensus exists. However, it is the role of institutions such as the Florida Heart Research Institute, which has made major contributions to our understanding of the care of the elderly, to provide the critical research which will help to inform the debate. What are the short and long-term outcomes of various therapeutic options? What are the most appropriate metrics for this population? (Longevity may be much less of an issue for an octogenarian than the quality of his remaining years.) Are there selection criteria which need to emerge specifically tailored for this elderly population? Recent research has focused on “frailty” as a risk factor for poor outcomes after various interventions. Originally described by Linda P. Fried in the 1990’s after years of observing and working with older patients, frailty in people 65 and older was defined by the presence of three or more of the following five criteria were present: unintentional weight loss of 10 pounds or more in the past year, self-reported exhaustion, weakness as measured by grip strength, slow walking speed and low physical activity. The presence of one or two of those criteria would identify a person as “pre-frail.” Although not universally accepted within the field, Fried’s work has helped to focus research and clinical decision-making, and elements of her criteria have even crept into surgical risk models.

 

However the debate regarding healthcare financing unfolds, it is clear that 1) care of the elderly will be a major point of discussion; and, 2) emerging research is critical in order to inform the debate in a meaningful and productive manner.