How Old is Too Old? Joint Replacements and the Changing Face of PM&R

“Is it safe to do joint replacement surgery on patients aged 95 and older? Is it worth it from a functional perspective?”

The field of PM&R is continually evolving. A driving force behind some impending changes is the aging population. Indeed, it is estimated that the number of individuals over the age of 85 in the United States will expand more than 90% by 2015. With this shift comes a multitude of new questions regarding medical care. One of these surrounds the issue of elective total joint replacements.

In our inpatient unit in recent months, we have encountered a significant increase in the number of patients over age 90 who have undergone these procedures. In researching this phenomenon, we discovered that patients over the age of 90 are considered “extremely elderly,” a term coined only recently.¹ In fact, nearly all articles we found on joint replacements use age 85, if not lower, as a cutoff to delineate an older population.^2-5; There are very few studies exploring outcomes associated with joint replacements on patients over age 90, and fewer on those aged 95 or 100.⁶ And yet our experience and anecdotal reports indicate that more procedures are being done on this population. This information is both surprising and worrisome.

It is anticipated that the number of joint replacements will triple in coming years. In 2004 alone, there were 660,000 total joint replacements, an increase of over 50% from 1997. In the same time period, the percentage of elective total joint replacements on elderly patients (greater than 85) increased from 22% to 27%.⁷ If projections prove correct, there will be an inordinate number of patients undergoing this procedure in the near future, and those within the extreme elderly population will likely skyrocket. Some studies that broach this topic (mostly with age cutoffs in the 80s) suggest outcomes are identical between younger and older patients;^3-4 however, others conclude that mortality increases as total joint replacement patients get older.⁵

Needless to say, the questions this issue raises are multifold and complex. Is it safe to do joint replacement surgery on patients aged 95 and older? Is it worth it from a functional perspective? Is it feasible from a cost standpoint? While it is undeniable that older individuals are generally healthier than in the past and that each case must be weighed in and of itself, these issues must still be resolved. Of course, the subject of surgery in the elderly is not confined to joint replacements, but it is perhaps one of the most pertinent to physiatrists at this point. As young professionals in this field, it seems germane to be cognizant of this trend and to consider its potential consequences, both good and bad. In this vein, it would also be worthwhile to spearhead studies to assess rehabilitation outcomes in this population.

Doug Elwood, MD
PGY4 – New York University PM&R

Anjali Sinha, DO
PGY3 – New York University PM&R

References

1. Michael E. Berend, et al. Total Joint Arthroplasty in the Extremely Elderly: Hip and Knee Arthroplasty After Entering the 89th Year of Life. The Journal of Arthroplasty 2003; 18(7): 817-823.
2. Victoria Anne Brander et al. Outcome of Hip and Knee Arthroplasty in Persons Aged 80 Years and Older. Clinical Orthopedics and Related Research 1997; 345: 67-78.
3. Mark W. Pagnano et al. Total Knee Arthroplasty for Patients 90 Years of Age and Older. Clinical Orthopedics and Related Research 2004; 418: 179-183.
4. Roger N. Levy et al. Outcome and Long Term Results Following Total Hip Replacement in Elderly Patients. Clinical Orthopedics and Related Research 1995; 316: 25-30
5. R. D. Ramiah et al. Ten Year Life Expectancy After Primary Total Hip Replacement. Journal of Bone and Joint Surgery [Britain] 2007; 89-B(10): 1299-1302.
6. E Krishnan et al. Primary Hip and Knee Arthroplasty Among Nonagenarians and Centenarians in the United States. Arthritis and Rheumatism 2007; 57(6): 1038-1042.
7. Sunny Kim. Changes in Surgical Loads and Economic Burden of Hip and Knee Replacements in the US: 1997-2004. Arthritis & Rheumatism 2008; 59(4): 481-488.

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